Inspection on 19/06/07 for 3 The Droveway

This inspection was carried out on 19th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 The Droveway 20/11/08

3 The Droveway 31/01/08

3 The Droveway 12/10/06

3 The Droveway 06/03/06

3 The Droveway 17/08/05

3 The Droveway 27/01/05

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 3 The Droveway Hove East Sussex BN3 6LF Lead Inspector Niki Palmer Key Unannounced Inspection 19th June 2007 3:30 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3 The Droveway Address Hove East Sussex BN3 6LF Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01273 563935 01273 563935 www.caremanagementgroup.com Care Management Group Limited Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is six (6). Service users must be aged between eighteen (18) and sixty-five (65) years on admission. Service users with a learning disability, who may also have an associated physical disability, can only be accommodated. 12th October 2006 Date of last inspection Brief Description of the Service: 3 The Droveway is one of many homes owned by Care Management Group (CMG), which is registered to provide accommodation for up to six adults with learning disabilities. Residents at this establishment have profound learning and physical disabilities. The home is located on the outskirts of Brighton and Hove. There is nearby access to some local amenities and public transport. A small car parking area is available at the home, although on street parking is permitted in the surrounding areas. The home is a bungalow consisting of six single bedrooms, two bathrooms / shower rooms and a good-sized lounge. There is a separate kitchen and dining area and garden to the rear and side of the property, which is accessible to wheelchair users. Prospective residents and their relatives are provided with written information regarding the services and facilities provided at the home prior to admission. The home’s most recent inspection report is available on request. The home’s fees as of 12 October 2006 range between £1450 - £2082 per person per week dependent on needs. 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at 3 The Droveway will be referred to as ‘residents’. This unannounced inspection took place on Tuesday 19 June 2007 and lasted four hours. This enabled the Inspector to observe the evening routine. Six residents were accommodated on the day of the inspection, four male and two female aged between 23 and 40 years of age. In order to gather evidence on how the home is performing, individual discussions took place with four members of staff and a Physiotherapist, whilst the majority of the inspection was undertaken with the newly appointed acting Manager of the home. Two care records were examined in some detail for the purpose of monitoring care. Other areas and documentation inspected included: medication practices, the provision of activities, quality assurance systems, complaints procedure and the systems in place to safeguard residents from harm, staffing levels and the provision of relevant training. All communal areas and individual rooms were seen. A detailed Annual Quality Assurance Assessment (AQAA) was completed and returned by the previous acting Manager of the home prior to the inspection. This provided the CSCI with comprehensive information in respect of how the service ensures that people using the service views are upheld and incorporated into what they do, how equality and diversity issues are promoted, identify any barriers to improvements that have been faced over the past six months and how the service plans to make improvements within the next 12 months. Following the inspection, telephone contact was made with a small number of relatives. Their views are reflected throughout this report. What the service does well: 3 The Droveway has good procedures in place to ensure that only residents whose needs can be met by the home are admitted. The compatibility of residents currently living at the home is good. The staff team work well together and help to cover additional shifts due to the home being short staffed at this present time. 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 6 The home has good systems in place to ensure that all complaints are dealt with appropriately. Residents are protected from potential harm, neglect and abuse through the home’s robust policies and procedures and through staff receiving appropriate training. Residents’ finances are managed well. What has improved since the last inspection? What they could do better: There are a number of outstanding requirements from previous inspection reports: Minimal improvements have been made to address the shortfalls within individual plans of care and health records. The home must ensure that care plans are up to date and contain detailed information pertaining to an individuals’ care. These must be consistent, reflect actual current practice and be regularly reviewed. The home must ensure that it implements it’s own systems for reviewing the level of care provided within the service and take the appropriate action to 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 7 rectify any shortfalls. This should be carried out at regular intervals and involve residents and relatives as much as is possible. The home has been without a Registered Manager since January 2006. Through the evidence that has been gained during this, previous inspections and conversations with relatives, it is evident that the lack of clear management arrangements is having a detrimental effect on residents, particularly in relation to care planning. Due to these failings and the failure of the Providers to identify and rectify key issues, the CSCI must consider whether any further action is necessary to ensure improvements are made. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home has good systems in place to ensure no person is accepted whose needs cannot be met. EVIDENCE: Due to the complex healthcare needs of the residents accommodated, it is crucial for the home to ensure that as much information as possible is gathered prior to admission in order to ensure that the home can meet their needs. CMG, the providers of the service, employs a team of centrally based assessment referral officers, who are responsible for considering and assessing all initial referrals for each of the care homes across the South East region. There have been no new admissions to the home since the last inspection. The compatibility of residents accommodated at this time is good. 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents’ personal and healthcare needs are at risk of not being met due to care plans not being implemented, completed and reflecting actual current practice. EVIDENCE: Following a number of concerns that were raised during the home’s last inspection in respect of the home’s care planning procedures, two care records were examined in some detail, which raised a number of concerns: All residents have a template plan of care in place, titled ‘All about me’. It was disappointing to note that minimal work has been undertaken to review and update care plans since the last inspection. The information that had been recorded within one person’s care plan in respect of meeting their personal care needs remained unchanged. In addition, it was concerning to note that this person’s health booklet remained incomplete and minimal information had been recorded and updated. These two requirements are outstanding. The 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 11 acting Manager confirmed that she plans to review and implement new care planning procedures within the next six months. The Manager commented that during her short period of time working at the home, she has observed that a number of specialist interventions and guidelines are not being routinely followed by care staff. She said that to address these shortfalls she has requested additional support from the Therapy Team to work with care staff and residents to familiarise them with specific interventions. Indeed, the Therapy Team were present on the day of the inspection and were observed to be working closely with staff. This will be followed up at the next inspection. Following the last inspection, daily care records have been combined with individual care plans. It was concerning to note that those seen remained brief, insufficiently detailed and not person centred to individuals’ needs. The home is required to maintain accurate and person centred daily records. These must include the details of any specialist interventions e.g. the outcome of all hospital appointments or visits by healthcare professionals. This is outstanding from the previous inspection report, despite the previous acting Manager stating in the AQAA that all plans of care and daily records are in accordance with person centred planning. All of the residents living at the home have profound physical and learning disabilities and are therefore reliant on care staff, their relatives and other health and social care professionals to act in their best interests and make decisions on their behalf about many aspects of their lives. Relatives confirmed that they are involved in this process as much as possible. Albeit that residents’ verbal communication is limited, staff working in the home were observed to interpret individuals’ subtle level of communication and include residents in the daily routines of the home wherever possible. Due to the capabilities of the residents living at the home, limited risk taking can be initiated, however detailed risk assessments are in place for all activities of daily living and personal health care needs. These are included within individual plans of care. Examples of those seen include bathing, swimming and a number of community activities. The returned AQAA stated that all care staff would benefit from additional training for risk management. This will be followed up at the next inspection. 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are mostly supported to experience a variety of different meaningful and stimulating activities. The provision of food is good, although residents would benefit from a more person centred approach towards daily routines within the home. EVIDENCE: CMG owns a development centre, which is accessed by a number of the organisation’s nearby care homes on a daily basis, Monday to Friday. This provides opportunities for five of the residents at 3 The Droveway to engage in informative and creative activities should they wish, including sensory stimulation, art, postural movement, Speech and Language Therapy, physiotherapy, music, and IT. There is no specific day care provision in place for one person at this current time, although significant improvements have been made since the last 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 13 inspection by the home to ensure that alternative meaningful activities are provided. These include a number of different in-house activities such as aromatherapy and massage, arts and crafts etc. and using facilities in the local community such as public transport, day trips to London and surrounding areas, visiting relatives, going to the local pub and shopping. 3 The Droveway has not had access to it’s own minibus for almost one year as it failed its MOT. Since this time the home has been reliant on using transport from other nearby CMG homes, consequently impacting on the number of community activities that residents can take part in (although it must be noted that residents have been making use of public transport facilities). Relatives commented that the home has been slow to rectify this matter and as a result one relative has written to senior management in an attempt to get this resolved. Staff spoken with assured the Inspector that a new minibus has been requested and that suitable provisions are being made. This will be followed up at the next inspection. Conversations with staff and relatives confirmed that visitors are always made to feel welcome to the home. All visitors are requested to sign in to the home on arrival in a book located at the main entrance of the building. The Inspector was invited to join residents and staff for the evening meal. All meals are prepared in the home by care staff who have undertaken the appropriate food hygiene training. All residents are encouraged to dine together in the dining area around the table. Due to the complex needs of some of the residents accommodated, additional support for eating and drinking is required as per individual guidelines that have been written by the organisation’s Speech and Language Therapist. Additional cutlery and aids are provided where necessary to promote residents’ independence. All food was noted to be pleasantly presented, although the mealtime period itself was noted to be quite busy. Two residents were being supported by two different members of staff at different times, which contributed to the evening meal appearing quite hurried and based around the needs of the staff, not residents. In addition, another person had dropped their cutlery and had to wait a considerable length of time for a member of staff to wash it up so that they could finish their meal. By this time, the person had become impatient, had tried eating the food with their fingers and had by mistake, dropped their plate onto the floor. The home is required to review the mealtime arrangements in order to ensure that the needs of the residents are prioritised. In addition, during the inspection, care staff were observed to be sat around talking with each other, whilst most residents were sat in front of the TV (without any observation or support from staff). On two separate occasions, the Manager had to remind staff of their duty towards the residents. 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 14 The observations noted above, were discussed with the acting Manager on the day of the inspection. Whilst it is recognised by the CSCI that inspections can seem daunting for some staff and of course the residents whose home it is, the observations made on the day of the inspection indicate that the home may on occasions be routinely run and that in some instances the routines of the care staff override the needs of the residents. As the Manager was aware of this and did take the appropriate action during the inspection, this has not been reflected as a requirement at this time, but will be followed up at the next inspection. 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst residents are supported to access a range of healthcare services to meet their physical and emotional well-being, care plans and health booklets fail to ensure that all residents’ personal and healthcare needs are identified and met. Medication practices are sufficient. EVIDENCE: All residents are registered with a local GP and dentist and are supported to all appointments as necessary. Due to the complex healthcare needs of residents, District Nurses visit the home on a regular basis. All personal care is carried out in the privacy of one of the communal bathrooms or in residents’ own bedrooms. All residents require a minimum of 2-1 support from staff; this is due to safe manual handling procedures. Since the last inspection, an additional hoist has been obtained. CMG employs a Speech and Language Therapist, Occupational Therapist and a Physiotherapist, who comprise the Therapy Team. The team works regularly in 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 16 3 The Droveway, whilst other specialist healthcare referrals are made as necessary. Four of the residents living at the home have epilepsy, for which they are prescribed emergency medication (rectal diazepam). Staff commented that they have received specialist training for these procedures since the last inspection, however the organisation’s policies state that they must be observed by senior care staff to administer this medication on at least three occasions before they are deemed competent. Whilst this is recognised by the CSCI as good practice, this inadvertently impacts on individuals’ being supported to go out into the local community with only one member of staff. In order to increase residents’ opportunities to engage in 1-1 community activities outside of the home, it is recommended that the home’s current policies and procedures are reviewed, based on individual risk assessments. In addition to the above, the home was required at the last inspection to ensure that all epilepsy management guidelines are clear and precise and that they include a brief history of the person’s seizures, a description of what form the seizure takes and clear instructions for staff to follow in the event of a seizure occurring. Whilst one person’s plan of care had been updated using the new format, their guidelines merely stated the type of seizures that they experienced, not a clear description of how they present (although it must be noted that there were clear instructions for staff to follow in the event of a seizure occurring). In light of the fact that only one person’s guidelines had been reviewed at the time of the inspection, this requirement is outstanding. Concerns were raised at the last inspection regarding how the home manages residents’ personal care needs in respect of maintaining pressure area care. It was reassuring to note that the Therapy Team were providing additional support to care staff on the day of the inspection in respect of this and individual guidelines had been updated. The home uses a pre-packed blister pack, which is delivered by the local pharmacy on a monthly basis. Only members of staff who have received the relevant training and have been assessed as competent in the administration of medicines are able to carry out this task, whilst only senior members of staff hold responsibility for the reordering and returning of medicines to the pharmacy. The acting Manager informed the Inspector that she raised concerns in respect of the administration of medicines, shortly after she took over the responsibility of managing the home. She noted that a number of errors were occurring and she observed staff to be ‘potting up’ medication in advance. It was pleasing to note that since this time the Manager has reviewed the home’s policies and procedures and spoken with a number of staff individually. She has also arranged for refresher training and has introduced a system for regular monitoring and auditing. The CSCI is satisfied with the action the 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 17 Manager has taken. The home’s compliance with this will be followed up at the next inspection. Clear guidelines are now in place for all residents who require medication on an as and when required basis (PRN). This is improved since the last inspection. In respect of the fact that minimal work has been undertaken by the home to ensure that all care plans and health booklets are up to date and reflect actual current practice, the CSCI considers the overall outcome for this area to be poor. 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good systems in place to ensure that all complaints are dealt with appropriately. Residents are protected from potential harm, neglect and abuse through the home’s robust policies and procedures and through staff receiving appropriate training. Residents’ finances are managed well. EVIDENCE: The home has a detailed complaints procedure in place, which was seen on the day of inspection. It details how a complaint can be made, how the complainant can expect it to be dealt with and includes the contact details of the CSCI. Since the last inspection the home has implemented a system to ensure that clear records of any concerns or complaints made are kept within the home. There have been no complaints received by the CSCI since the last inspection. The home has a detailed Adult Protection and whistle-blowing policy and procedure in place in accordance with local multi-agency guidelines. Staff spoken with confirmed that refresher training has been provided since the last inspection and that they would feel confident in reporting any concerns of suspected abuse and/or poor practices within the home. One alert has been reported by the home since the last inspection. This was appropriately dealt with. A sample of residents’ monies, including expenditure receipts were seen on the day of inspection and found to be in order. 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 3 The Droveway offers a friendly and relaxed environment that is kept in good decorative order. It presents as a clean, well-maintained and homely place to live. EVIDENCE: 3 The Droveway consists of six single bedrooms, two bathrooms / shower rooms and a good-sized lounge. Since the last inspection the lounge area has been re-carpeted and hallways and some doors have been repainted. New leather sofas had very recently been purchased by the home. Relatives did comment that this has made a vast improvement, however the home was slow to purchase these. All areas seen were noted to be clean, well-maintained and homely. It was evident that residents have been involved (as much as possible) in choosing their own furniture, accessories and décor. All residents have their own TV, video and stereo equipment in their rooms. There are a number of 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 20 photographs displayed throughout the home of each of the residents, all of which have been nicely framed and presented. The home has a good-sized garden, which is accessible to wheelchair users. Staff confirmed that they hope to develop this area into a sensory garden in the near future. The acting Manager confirmed that all staff are responsible for the day to day upkeep of the home including laundry. A part-time cleaner is shared with a nearby CMG care home to work at 3 the home for two mornings per week. 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the home’s robust recruitment procedures. A good level of staff training is provided. EVIDENCE: In addition to the acting Manager, the home employs a total of nine care staff. Only one person has obtained at least NVQ Level 2 in Care, although two have almost completed this course, whilst another person is working towards this. Staff spoken with confirmed that a good level of training is offered by CMG and that individual training needs are identified through regular staff supervision. Recent training includes: rectal diazepam, first aid, medication, safeguarding adults and eating and drinking. This is improved since the last inspection. 3 The Droveway has continued to experience difficulty in recruiting new care staff since the last inspection. There continues to be three full-time vacancies and a vacant night worker post. Up until recently, some shifts have been covered by agency staff, although in order to improve the consistency of care some care staff have offered to work additional hours, whilst staff from other 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 22 nearby homes (also owned by CMG) have been asked to cover some shifts. The Manager commented that one of her main priorities is to recruit suitably experienced and dedicated staff. Interviews for new applicants were taking place on the day of inspection. All job advertisements are advertised in local newspapers, on CMG’s website and at a number of different job fairs. All initial information is coordinated by the organisation’s Human Resources department who are responsible for sending out application forms, alongside the required Criminal Record Bureau (CRB) and Protection of Vulnerable Adults First (PoVA) check, health declaration and Equal Opportunities Monitoring Form. The recruitment files for two newly appointed members of staff were examined. It was pleasing to note that application forms were sufficiently detailed, two satisfactory written references had been obtained and there was evidence of a PoVA First check and Criminal Record Bureau (CRB) check in place. All staff confirmed that they have clear job descriptions and fully understand their roles and responsibilities. Copies of job descriptions were seen in individual recruitment files. Two members of staff spoke openly with the Inspector on the day of inspection regarding the home’s induction processes. These are improved since the last inspection. 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Albeit that a new Manager has recently been appointed, evidence gathered during this and previous inspections indicate that the home is not managed effectively and in the best interests of residents. EVIDENCE: The home has been without a Registered Manager since January 2006, despite repeated requirements being made at the last two inspections. Since this time, there have been three acting Manager’s in succession with very little guidance and support from senior management. These are concerns that relatives have commented upon since January 2006. This continues to impact on the level of care and support provided particularly in respect of the home’s care planning procedures. 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 24 The current acting Manager had been in post for almost two weeks on the day of inspection. She has been in working care for approximately 25 years working in various positions including other CMG homes. She has achieved NVQ Levels 3 and 4 and a Registered Manager’s Award (RMA). It remains an outstanding requirement from the past two inspection reports for an application to be submitted to the CSCI to begin the process of registering a Manager. It must be noted that the CSCI was not notified of the most recent change in the home’s management arrangements. The acting Manager and the Registered Provider were reminded that the CSCI must be notified in writing when either the Registered Provider and/or Manager of the home proposes to be absent from the home for a period of 28 days or more or when there is a change in the overall management arrangements. Concerns were raised during the home’s previous inspection report regarding the home’s own quality assurance systems. Despite CMG having provided the home with a quality assurance manual, this is still to be implemented. It is of concern that recent inspections have identified a number of omissions, errors and requirements, which the service should have identified themselves through their own effective quality assurance systems. Due to these failings and the failure of the Providers to identify and rectify key issues, the CSCI must consider the most appropriate action. A number of concerns were raised at the home’s last inspection regarding a number of health and safety matters within the home. It was pleasing to note that the following have since been rectified: - All electrical appliances have been recently checked (PAT tested) to ensure that they are safe to use. - Hazardous substances are now stored correctly as per their risk assessment. - All hot water outlets are now regulated to ensure that they do not exceed the recommended 43°C. - Suitable laundry facilities and arrangements are in place to prevent infection and the spread of infection at the home. 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 3 X 1 X 1 X X 3 X 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 YA18 Regulation 15(1)(2) (a-d) Requirement That care plans are up to date and contain detailed information pertaining to an individuals’ care. These must be consistent, reflect actual current practice and be regularly reviewed [Outstanding from the last inspection]. That health booklets are up to date and provide detailed written information for staff to follow in relation to pressure area care, epilepsy, weight, medication and any other healthcare needs. These must be regularly reviewed [Outstanding from the last inspection]. That accurate and person centred daily records are maintained in respect of each resident [Outstanding from the last inspection]. That the mealtime arrangements are reviewed to ensure that the needs of the residents are prioritised. That individual epilepsy management guidelines are clear and precise. These must DS0000060763.V337499.R01.S.doc Timescale for action 31/12/07 2. YA6 YA19 15(1)(2) (a-d) 31/12/07 3. YA6 17(1)(a) (3)(a) 31/12/07 4. YA17 12(1)(a) 31/12/07 5. YA6YA6 YA19 12(1)(a) (b) 31/12/07 3 The Droveway Version 5.2 Page 27 6. YA37 18(1)(a) 7. YA39 24(1)(a) (b) 24(3) include a brief history of the person’s seizures, a description of what form the seizure takes and clear instructions for staff to follow in the event of a seizure occurring [Outstanding from the last inspection]. That an application for a 31/12/07 registered manager be forwarded to CSCI for processing [Outstanding from the last two inspections]. That effective quality assurance 31/12/07 systems are in place and implemented in order to review the quality of care provided at the home [Outstanding from the last inspection]. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA19 YA13 YA18 Good Practice Recommendations That in line with Valuing People, Health Action Plans are implemented. That in order to increase residents’ opportunities to engage in 1-1 community activities outside of the home, the home’s policies and procedures for the administration of emergency medication used in epilepsy are reviewed based on individual risk assessments. 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 3 The Droveway DS0000060763.V337499.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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