Inspection on 31/01/08 for 3 The Droveway

This inspection was carried out on 31st January 2008.

CSCI found this care home to be providing an Adequate service.

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 6 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 19/06/07

3 The Droveway 12/10/06

3 The Droveway 06/03/06

3 The Droveway 17/08/05

3 The Droveway 27/01/05

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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 31st January 2008 14:15p 3 The Droveway DS0000060763.V357961.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.V357961.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.V357961.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 Ltd Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 3 The Droveway DS0000060763.V357961.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. 19th June 2007 Date of last inspection Brief Description of the Service: 3 The Droveway is a care home, which provides personal care and accommodation for up to six people with profound physical and learning disabilities. The home is owned and run by Care Management Group (CMG) who are a large organisation that provides care for people with learning 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. The garden 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 5th February 2008 ranged from £1633.45 - £2398.41 per person per week dependent on needs. 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. 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 key unannounced inspection took place on Thursday 31st January 2008 and lasted five 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. The appointed Manager was available for the first half of the inspection, whilst discussions were held with four members of staff. Residents living at the home were unable to provide feedback and give their comments. For the purpose of monitoring care, two individual plans of care were looked at. Other records and documentation seen included: the home’s medication procedures, complaints procedure and the systems in place to safeguard people from harm, staff recruitment records and the provision of training, the home’s quality assurance systems and some health and safety records. Following the inspection, telephone contact was made with relatives. Some of their comments have been reflected throughout this report. The Commission did not request an Annual Quality Assurance Assessment (AQAA) prior to this inspection as one had been completed prior to the last inspection, less than 12 months ago. What the service does well: The compatibility of residents living at the home remains good. 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. 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. 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 6 Residents are supported to experience a variety of meaningful and stimulating activities, which encourages them to develop skills and maintain relationships with family and friends. The Manager makes sure that any concerns or complaints are dealt with quickly, efficiently and to the satisfaction of the complainant. Residents’ health and personal care needs are well supported by CMG’s therapy team. Residents are protected by the home’s robust recruitment procedures. Residents’ personal finances are managed well. What has improved since the last inspection? Following the serious concerns that were raised at the last inspection, the Commission held a Management Review Meeting and met with a senior representative of CMG. The home was required to submit a detailed improvement plan to detail what actions they would be taking to improve the service and to meet all of the requirements within the given timescales. Since this time CMG’s quality assurance inspectors and senior staff have monitored the home on a monthly basis and at regular performance improvement meetings. The Commission received regular written updates of the progress made and evidence was seen over the duration of this inspection that the home has indeed improved many areas and outcomes for people who use the service: The Manager has reviewed and improved all care plans and records. Residents and staff are much better supported by the home’s improved care planning procedures. In addition regular health monitoring checks and records are now kept. The Manager has worked with the GP to make sure that all residents with epilepsy have clear and precise guidelines in place for staff to follow. In addition, the home has reviewed epilepsy policies and procedures for the administration of emergency medication. This has increased residents’ opportunities to engage in community activities. The mealtime arrangements have been reviewed. Residents now receive 1-1 support where necessary in a relaxing and calm environment. Feedback from relatives and staff was positive in respect of the relatively new Manager who was appointed in June 2007: “Everything has changed under her management: care records, how shifts work. This is definitely for the better” 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 7 ‘She’s definitely getting into the swing of things’. What they could do better: 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.V357961.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.V357961.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. The home has good systems in place to make sure that no person moves into the home whose needs cannot be met. EVIDENCE: The appointed Manager said that she is in the process of reviewing and updating the home’s Statement of Purpose and Service Users’ Guide; therefore these were not inspected on this occasion. This will be followed up at the next inspection. Due to the high support needs of the residents accommodated, it is important for the home to make sure that as much information as possible is gathered prior to admission in order to make sure that the home is suitable and can meet their needs. CMG employs a team of centrally based Assessment Referral Officers, who are responsible for considering and assessing all initial referrals for each of the homes alongside the Manager. There have been no new admissions to the home since in the past 18 months. The compatibility of residents remains good. 3 The Droveway DS0000060763.V357961.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 good. This judgement has been made using available evidence including a visit to this service. Residents and staff are better supported by the home’s improved care planning procedures and records. EVIDENCE: All of the residents living at the home have profound physical and learning disabilities with additional healthcare needs. It is therefore important that their individual needs are clearly outlined in care records in order to support care staff. Following a number of concerns that were raised at the last two inspections in respect of this, two care records were looked at in some detail: The Manager has reviewed and improved all care plans since the last inspection: The home uses a number of different care records; care plans, health booklets, handover reports, daily diaries, personal care records, monthly key worker reports and separate health records. 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 11 Care plans are called ‘All about me’. These contain a pen portrait of each person, including where they grew up and went to school etc. Photos of ‘people who are important to me’ and ‘my likes and dislikes’ are clearly recorded. All have been written in the first person and contain up to date detailed information and guidelines for staff to follow to meet all activities of daily living such as ‘how I communicate to make my needs known’ and ‘my preferred smells, sounds, tastes and touch’. In addition to these, comprehensive guidelines are in place to support staff in meeting other specialist care needs such as pressure area care, postural management and physiotherapy. Photos support the guidelines. Staff said that the detailed care plans are useful, particularly for new members of staff, but that they mostly refer to and use daily records and personal care records. Personal care records provide an overview of residents’ daily routines including the assistance required with all activities of daily living. Copies of all guidelines (as above) are kept within these including eating and drinking and epilepsy management guidelines. New hardback diaries are now being used for staff to record general daily activities. Two were seen. It was noted that the information contained within these was variable e.g. some staff had written more than others, however mostly they were found to be brief and in some instances use inappropriate and negative language (concerns that have been raised in previous inspections): “Has been very vocal this AM” “Not cooperative at all, lifting and throwing things” “Moody this PM and moaning a lot. Not sociable”. Due to the number of different records being kept, it was not easy for the Inspector to see a clear audit trail of what action and interventions had been taken by staff to make sure that residents’ health and personal care needs are being met, although the Manager and care staff said that they do find the recording methods easy to use, understand and follow. These shortfalls were discussed with the Manager on the day of inspection. It is recommended that the Manager review the number of different daily records and recording methods that are currently being used in order to provide a clearer audit trail in respect of how resident’s health and personal care needs are being met. 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 said that 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 12 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. Clear communication guidelines were seen within individual care records. Due to the capabilities of the residents living at the home, limited risk taking can be initiated, however risk assessments are in place for all activities of daily living and personal health care needs. These are now kept separately from care plans. Examples of those seen include bathing, using the hydrotherapy pool and a number of community activities. 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 13 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, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to experience a variety of meaningful and stimulating activities. Residents benefit from a more person centred approach towards mealtimes within the home. EVIDENCE: CMG owns a development centre, called the Brelade, which is open only to CMG homes Monday to Friday. This currently provides opportunities for five of the residents at 3 The Droveway to take part in informative and creative activities should they wish e.g. sensory stimulation, art, postural movement, hydrotherapy, physiotherapy, music, and IT. There is currently no specific day care provision in place for one person, although a number of different activities such as aromatherapy and massage, arts and crafts and using community facilities such as the local parks, pubs and shopping centres do take place on a 1-1 basis for this person. This person is 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 14 also supported to day trips out and to visit their relatives during the day. Relatives said that this person would benefit from attending the Brelade centre and integrating with his peers, although they understand that funding issues are preventing him from doing so at this time. The Manager said that she is aware of this matter and that it is being looked into. The home’s progress with this will be followed up at the next inspection. The home has not had access to it’s own minibus for almost 18 months after it failed its MOT. Since this time the home has been reliant on using transport from other nearby CMG homes and public transport. Relatives said at the last inspection that they had raised this matter with senior representatives of CMG in an attempt to get this resolved. The Manager explained that the home did have regular access to a ‘borrowed’ minibus up until a few days prior to this inspection. She told the Inspector that she has been assured that a new minibus should be arriving in the next 8-10 weeks. The Manager and staff said that activities outside of the home have been improved (largely due to transport arrangements). Residents have recently been to Portsmouth for the day and ice-skating at Guildford Spectrum. A new activities and communications board was seen on the wall in the dining area. This contains photographs of all the residents and has pictorial weekly planners. It must be noted however that this had not been updated for over two weeks. This matter was raised with staff. CMG has an indoor hydrotherapy pool located at the rear of a nearby home. This has been certified as safe for use since the last inspection. Some staff have already received training to enable them to support residents with this, although most residents use it on a regular basis with support from staff from the Brelade. Conversations with staff and relatives confirmed that visitors are always made to feel welcome to the home. Relatives also said that the staff team are good at keeping them informed of any important issues or health matters as they arise. 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. The support offered by staff was improved since the last inspection. All residents have clear eating and drinking guidelines in place, which were seen in individual care records. Since the last inspection, the Community Learning Disability Team (CLDT) has taken over the overall responsibility for Speech and Language Therapy support at the home. They are responsible for assessing, planning, reviewing individual needs and providing training to staff. 3 The Droveway DS0000060763.V357961.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 good. This judgement has been made using available evidence including a visit to this service. Residents are supported to access a range of healthcare services to meet their physical and emotional needs. Improved care plans and records help to make sure that personal and healthcare needs are met. Medication systems are sufficient. EVIDENCE: All personal care is carried out in the privacy of one of the communal bathrooms or in residents’ own bedrooms. Baths/showers are carried out at flexible times according to the preferences of each person. These are outlined in individual care records. All residents are registered with a local GP and dentist and are supported to all appointments as necessary. CMG employs their own Occupational Therapist and Physiotherapist. Up until recently, they also employed their own Speech and Language Therapist who worked regularly into 3 The Droveway (due to the complex physical and healthcare needs of the residents in respect of communication and eating and 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 16 drinking). This person was made redundant by the organisation, which raised some level of concern by care staff, Managers, relatives and other healthcare professionals. The Commission raised these concerns directly with a senior representative of CMG who confirmed that the Regional Director is monitoring the situation closely. (As already mentioned, the CLDT are now working closely with the home). CMG have assured the CSCI that if any problems arise such as a delay in residents and staff receiving support due to current waiting lists, then a freelance person will be requested on an individual basis. It must be noted that the Manager and care staff commented on the day of inspection that support so far has been good from the CLDT although some new staff are having to wait a short time for training, which in the past would have been picked up quickly from the previous therapist. No concerns were raised by the Inspector on the day of inspection. Revised care plans were found to be up to date and sufficiently detailed in respect of meeting personal and healthcare needs, including clear epilepsy management guidelines. Those seen clearly stated what the person’s seizures look like and what staff need to do in the event of a seizure occurring. This is improved since the last inspection. Staff said that epilepsy training is now being provided by one of CMG’s qualified trainers. They explained that the training now includes a competency assessment in the safe administration of emergency medication (rectal diazepam). This means that staff now only have to be observed once before they can take residents out into the community. The home’s policies and procedures have been amended accordingly. This is improved since the last inspection. All residents have individual CMG health booklets in place. Concerns were raised at the last two inspections in respect of these. Two were seen on this occasion and although minimal information had been added to them, there was evidence within personal daily records and separate health records that regular monitoring is in place. As already mentioned it is recommended that the Manager review the number of different daily records and recording methods that are currently being used. Staff said that three residents are awaiting the delivery of new wheelchairs and/or comfy seating. This has been arranged by the home and CMG’s physiotherapist through the Wheelchair Service. Two medication errors have been reported to the CSCI since the last inspection; these were discussed in detail on the day of inspection. The first one was caused as a result of a member of staff rushing in the morning and giving the wrong medicine to the wrong person. The appropriate action was taken immediately by the home and refresher training was provided to the member of staff responsible. 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 17 The second error occurred due to a breakdown in communication between the home, hospital, GP and pharmacist following a resident being discharged home from hospital. This error was not recognised until after several weeks. The appointed Manager conducted a thorough investigation into this, which highlighted that all parties had played a part in this breakdown in communication. As a result of this, new policies and procedures have been put into place and additional training has been provided to staff. A community pharmacist had visited the home two days prior to this inspection to undertake a detailed inspection of the home’s medicines. The report identified that all medicines were correct and in order. It was noted however, that the lighting in the area where medicines are stored is very poor, although staff did say that they generally only administer medicines in the dining area where lighting is better. It is recommended that additional lighting be provided in this area. 3 The Droveway DS0000060763.V357961.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 adequate. This judgement has been made using available evidence including a visit to this service. The home has good systems in place to make sure that any concerns or complaints are dealt with quickly and efficiently. Residents will be better safeguarded from potential harm, neglect or abuse once all staff have received refresher training in this area. Residents’ financial interests are safeguarded. EVIDENCE: The home has a clear complaints procedure in place, which was seen on the wall near the entrance to the home. It gives clear guidance with regards to how a complaint can be made and how the complainant can expect it to be dealt with. One complaint has been made to the home since the last inspection. Records seen and those spoken with confirmed that the Manager handled and resolved this matter quickly and efficiently. Whilst it was pleasing to note that the Manager is keeping a record of any complaints received including the action taken, it was noted that they were accessible to all persons within the home. It is recommended that these be kept securely. No complaints have been received by the CSCI since the last inspection. The home has an up to date Safeguarding Adults from Abuse and whistleblowing policy and procedure in place in accordance with local multi-agency guidelines, although staff said that the home’s general policies and procedures file is difficult to use, as there is no clear index at the front of the file for staff to follow. Staff spoken with were reasonably clear about the action they would take in the event of recognising and reporting suspected or actual harm, 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 19 neglect and abuse, although some staff have not received any refresher training or guidance from the Manager in respect of using the revised guidelines; some since 2005. Staff said that they would benefit from refresher training in this area. This will help them to become confident in using the revised multi-agency guidelines. A requirement has been made in respect of this. No alerts have been made since the last inspection. The appointed Manager confirmed that all residents have their own bank accounts. Where possible, relatives are encouraged to safeguard individuals’ financial interests. The Manager is in the process of arranging to become a named trustee for some residents. Evidence of recent correspondence between the home, banks/building societies and CMG was seen. All residents’ daily monies are kept securely within the home. A sample of these were checked and found to be in order. A clear audit trail including receipts had been kept. 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 20 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 and homely place to live. EVIDENCE: 3 The Droveway consists of six single bedrooms, two bathrooms / shower rooms and a good-sized lounge. All areas of the home were seen, which were noted to be clean, reasonably well-maintained and homely. 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 photographs displayed throughout the home of each of the residents, all of which have been nicely framed and presented. One relative commented that after six months, the home has arranged to have one of the bedrooms recarpeted. The home has a good-sized garden, which is accessible to wheelchair users. 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 21 The home has talked in the past about developing a small area within the garden into a sensory area. The 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 the home for two mornings per week. 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 22 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, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The improved numbers of staff employed helps to make sure that residents are supported by enough members of staff on duty. Whilst residents are protected by the home’s recruitment procedures, the home fails to make sure that all staff receive a thorough induction to the home. EVIDENCE: In addition to the appointed Manager, the home employs a total of 12 care staff. Three have achieved at least NVQ Level 2 in Care, whilst all others have been enrolled to start working towards this qualification in February 2008. 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. One person said: “The training is very good. I have been on about eight training courses in the past two months. I am really looking forward to the hydrotherapy training” 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 23 Recent training includes: manual handling, epilepsy, person centred planning, first aid, gastrostomy care and feeding, medication and chest physiotherapy. The Manager said that she is aware that some mandatory training is outstanding for a small number of staff, although she plans to deal with this. The home has struggled to recruit and retain staff over the past two years, although the Manager and care staff confirmed that staffing levels are improved since the last inspection. There were no vacancies on the day of this inspection. The Manager explained that the home is on occasions using staff from other CMG homes to cover training days, although no agency staff have been used in over three months. The Manager described the current staff team as “enthusiastic”. Feedback from relatives about staff was also positive. Staff recruitment records for two recently employed members of staff were seen. Their application forms were sufficiently detailed and there was evidence of police checks, photo identification, two written references and permits to work being obtained prior to employment. Copies of job descriptions were seen in individual recruitment records. The Manager said that the home uses a Skills for Care induction process and booklet for new staff to work through under the supervision of a senior member of staff. It was disappointing to note that out of the two that were requested, only one was available. The majority of this was blank, with the exception of a policies and procedures list all of which had been signed as read and understood on the person’s first day. The Manager explained that this person had started working at the home in September 2007, although was still on their ‘probationary’ period, which is normally only three months. A requirement has been made in respect of this. 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 24 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, 40 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the home has made good progress in improving the overall conduct and management of the home since the last inspection, which has in turn improved the outcomes for people who use the service, the Commission will need to see evidence that this is sustained over a reasonable period of time. EVIDENCE: The home has been without a Registered Manager since January 2006, despite repeated requirements being made at the last three inspections and written assurances from CMG that this will be dealt with. During this time, there have been three acting Managers in succession. The current appointed Manager has been in post since June 2007. She has been in working care for approximately 25 years including managing another CMG home. She has achieved NVQ Levels 3 and 4 and a Registered Manager’s 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 25 Award (RMA). It remains an outstanding requirement from the past three inspection reports for an application to be submitted to the CSCI for a qualified and competent person to become registered. Due to the organisation’s failure to take the appropriate action, a warning letter has been sent to the Registered Provider as a result of this inspection. Not withstanding the above, improvements have been noted in the overall management of the home since the last inspection. This was also reflected by staff and relatives: “Everything has changed under her management: care records, how shifts work. This is definitely for the better” ‘She’s definitely getting into the swing of things’. There have been recent changes in the management structure of the team. A senior member of staff has been promoted to Deputy Manager and two support workers have been promoted to senior carers. Seeking feedback from residents is challenging for the home due to residents’ high support needs and limited verbal communication skills. Relatives did confirm however that their feedback and views are regularly sought. CMG employ their own quality assurance team who visit each of the homes on a monthly basis. The purpose of these visits is to undertake an inspection of the service based on meeting the National Minimum Standards using the guidance of the KLORA (key lines of regulatory assessment, produced by the CSCI). Copies of these visits alongside regular updated improvement plans have been forwarded to the CSCI. These increased quality-monitoring checks have helped to improve the standard of care, particularly in respect of care records, staffing and general conduct of the home. As already mentioned, the home’s policies and procedures files are difficult for staff to use. It is recommended that an index page that can be crossreferenced be put at the front of the file. This will make the files easier for staff to use and policies and procedures more accessible. A number of health and safety records were seen during the inspection. These confirmed that all appliances and regular health and safety checks including fire-fighting equipment are frequently carried out. Staff said that senior members of staff are responsible for checking certain things on a weekly basis e.g. first aid box, lighting, hot water temperatures and fire alarms. It was noted within the weekly record checks that one person’s bedroom intercom is not working and has not worked over a considerable length of time. Albeit that staff said that this has never been used and that the person does not require it, there was nothing documented within the records to show 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 26 what action (if any) had been taken by the home to report the matter and get it rectified. A requirement has been made in respect of this. 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 27 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 2 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 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 2 X 2 X 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 28 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 YA23 YA35 YA40 Policies and procedures must be easily accessible. 2. YA35 18(1)(a) (c)(i) That all new care staff receive a thorough induction to the home within their first 12 weeks of appointment. Documentary evidence must be available for inspection. 3. YA37 18(1)(a) That an application for a 30/06/08 suitably qualified and competent person to become registered as the manager of the home be submitted to the CSCI. [Outstanding from the last three inspections]. 4. YA42 12(1)(a) That regular health and safety 29/02/08 monitoring checks and records clearly identify what action has been taken by the home when it has been identified that DS0000060763.V357961.R01.S.doc Version 5.2 Page 29 Regulation 13(6) 18(1)(c)(i) Requirement That safeguarding adults from abuse refresher training be provided to staff in line with revised multi-agency guidelines. Timescale for action 31/03/08 31/03/08 3 The Droveway something is in need of repair. 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. Refer to Standard YA6 YA19 Good Practice Recommendations That the Manager review the number of different daily records and recording methods that are currently being used in order to provide a clearer audit trail in respect of how resident’s health and personal care needs are being met. That additional lighting is provided in the area where medicines are stored. That a record of all complaints made including details of any investigations and any action taken be stored securely. That an index page that can be cross referenced is put at the front of the home’s policies and procedures files in order to make them easier for staff to use. 2. 3. YA20 YA22 4. YA40 3 The Droveway DS0000060763.V357961.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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