CARE HOME ADULTS 18-65
30 Broad Lane Upper Bucklebury Nr. Reading Berkshire RG7 6QJ Lead Inspector
Stephen Webb Unannounced Inspection 16th January 2006 10:30 DS0000011147.V272667.R01.S.doc Version 5.0 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 DS0000011147.V272667.R01.S.doc Version 5.0 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. DS0000011147.V272667.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 30 Broad Lane Address Upper Bucklebury Nr. Reading Berkshire RG7 6QJ 01635 871191 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) londonroad@tiscali.co.uk Milbury Care Services Limited ***Post Vacant*** Care Home 6 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4), Physical disability (2), of places Physical disability over 65 years of age (2) DS0000011147.V272667.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25th July 2005 Brief Description of the Service: This service provides a ‘home for life’ to five residents, of both genders, with learning and some physical disabilities. It is operated by the Milbury group. The service aims to enable service users to live a fulfilled life underpinned by “The Five Accomplishments of Ordinary Living” (John O’Briens). The home operates within a two storey detached house in Upper Bucklebury, having been relocated from its previous location in Lambourne, in Autumn 2002. The house is located on a main road but is set back from this, and has a good sized rear garden. The new unit manager commenced in post in July 2005. DS0000011147.V272667.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, carried out between 10.30am and 3.30pm on16/1/06. A support worker initially assisted the inspector, then later the unit manager. The inspection included the examination of relevant records, discussion with staff and the manager, a tour of most of the unit and some time informally observing service user interactions with staff. The inspector also ate lunch with service users. Although the inspection indicated some positive developments such as improvements in recruitment, and systems implemented by the new manager, there remain a number of areas of concern and further development and some long-standing requirements from previous inspection reports, which have not been addressed, none of which are within the direct control of the unit manager. The concerns regarding this unit will be the subject of a separate letter to Milbury who are the registered providers. What the service does well:
The Person Centred Plans (PCP’s) would be a useful format to record the needs and aspirations of service users, and evidence their changing needs and skills development, but were not current documents. The basic rights of service users are respected and the manager has plans to develop their involvement in day-to-day decision making. The staff work to maximise the dignity of service users when supporting personal care and service users can move about the unit freely, though all require staff support when out in the community. The manager has plans to develop the garden facilities, to include sensory planting and raised flower-beds to encourage greater service user involvement in this area. The manager reported that she was usually able to ensure that same-gender personal care support was available, though at times this was via the use of agency staff of specific gender to balance shifts. All of the permanent staff have attended in-house training on the protection of vulnerable adults. DS0000011147.V272667.R01.S.doc Version 5.0 Page 6 The unit has an appropriate complaints procedure and previous recorded complaints have been addressed appropriately. It would be good practice for the Regulation 26 visitor to countersign the complaints log at each visit to confirm their monitoring of this record. The bedrooms are satisfactorily decorated and individualised to reflect the personality and interests of their occupant. What has improved since the last inspection? What they could do better:
The care plans (Person Centred Plans), are not up to date and require complete review, to remove old formats and address the full range of current information, necessary information for effective ongoing care planning. The previous practice of updating care documents by placing stickers over old information and writing over it, is inappropriate and should not continue as it destroys historical information and evidence of ongoing change and development. The individual activity plans also required review to broaden their range and reduce their over-reliance on domestic tasks as activities.
DS0000011147.V272667.R01.S.doc Version 5.0 Page 7 There is a need for all staff to receive training on the whistle blowing policy, and on behavioural awareness. Any future instances of restraint must be reported to the inspector as a Regulation 37 notification. A programme of six-monthly review of service user care plans should be established. The communication skills of service users should be reviewed by a speech and language therapist, to seek to further develop their communication repertoire. The quality and readability of care records would be significantly enhanced by the provision of a computer to the unit. This would also enable a simpler process for update and review of these documents. There remains room for further improvement in the level of community participation and access by service users, and in their involvement in the preparation of drinks, snacks and meals. The records of health-care and monitoring were insufficient and not maintained up-to-date. These records require complete review to ensure that they are brought up to date and maintained as such. A previous requirement to improve the service user version of the complaints procedure remained outstanding, pending receipt of an example being devised in another Milbury unit. The quality of the physical environment continues to fall beneath acceptable standards in a number of areas. Outstanding requirements on various aspects of the premises should be addressed to bring these areas up to a suitable standard. There are health and safety concerns regarding the standard of cleanliness in the kitchen, the toilet flooring, the outstanding concerns raised in the Legionella survey, and the uneven garden patio, which must be addressed. There is a need to establish a systematic quality assurance cycle, seeking the views of relevant parties, and a cycle of annual review of care and annual development planning. Copies of the reports arising from these processes should be forwarded to the CSCI. 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. DS0000011147.V272667.R01.S.doc Version 5.0 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 DS0000011147.V272667.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of the standards in this section were examined on this occasion. Standards 1, 2 and 5 were examined at the previous inspection, and found to be met. DS0000011147.V272667.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, At present the current needs, wishes and aspirations of the service users are not addressed effectively within the care plan or other records, many of which are out of date and in need of urgent review. There is a need for a thorough review of the entire care planning system. EVIDENCE: Each service user has an individual person Centred Plan (PCP) and a separate health-care plan, which have the potential to be effective working documents. However, these were not up-to-date and contained a mixture of current and previous recording formats, some of which were useful while others were not in use. A family contact sheet had been included within the record as previously recommended, but this was a hand-written sheet of paper rather than a typed format, which would tend to detract from its importance. All of the PCP’s require rewriting and updating, and the removal of redundant formats. Old information should be archived. The PCP should reflect the current needs and wishes of the service user to enable ready access to the necessary information by staff.
DS0000011147.V272667.R01.S.doc Version 5.0 Page 11 The previous practice (prior to the current manager’s arrival), of updating care documents by placing stickers over the old information is inappropriate as it obscures relevant historical information. The PCP’s contained a lot of detailed information on individual preferences, likes and dislikes and activities, but the usefulness of this was unclear as many documents were either undated or dated from over a year ago. The activities plans were particularly old documents and contained a lot of domestic household chores defined as activities, rather than sufficient genuine activities in and outside the unit. These plans all require complete review. The individual fire evacuation plans were good practice, though these, too, should be reviewed to ensure they remain relevant. The incident records in one file indicated a series of short restraints in what appeared to be inappropriate circumstances, all by the same (agency), member of staff, including three instances on one day. Not only was there no evidence to justify these restraints, but these appear to have been contrary to the individual’s written behaviour management guidelines. The manager clarified that the agency staff member concerned had left and the agency had been informed of the concerns. Staff have been told that these were inappropriate responses to manage the behaviour of the service user, and there have been no further instances. It is of concern that this practice went unchallenged for some time, and this may indicate a need for further training input to staff on whistle-blowing, as well as better monitoring of incident records. (See Standard 35 later for requirement). The guidance is clear that physical intervention should only be used as a last resort and Regulation 13(7) states that “The registered person shall ensure that no service user is subject to physical restraint unless restraint of the kind employed is the only practicable means of securing the welfare of that or any other service user and there are exceptional circumstances”. I am also concerned that I was not notified of this issue under Regulation 37. Please advise whether the matter was reported to the relevant vulnerable adults protection team and whether the individual was referred to the POVA list by the agency. Please provide copies of any related reports or correspondence. All members of the current staff team have received NCI (Non-violent Crisis Intervention) training within the past twelve months. It is essential that all staff receive the required annual training updates in this area, and the presence of this training on the staff training record spreadsheet was noted.
DS0000011147.V272667.R01.S.doc Version 5.0 Page 12 Any future instances of restraint must be reported to the CSCI as a notification under Regulation 37. The manager reported that she will very soon have more or less a full staff complement and plans to completely review the care planning and recording system within the unit. This should be completed within the next two months as it is the basis of the care provided to the service users. The review should include the PCP’s, health-care plans, risk assessments, behaviour management plans, and the records of individual likes, dislikes and needs. The process will be led by keyworkers with management overview and in discussion with the team, (and clearly should involve consultation with the service users wherever possible and also involve the parents) to ensure the quality and accuracy of the information recorded. The requirement to complete this review will be one of the subjects of a separate letter to Milbury, who are the registered providers of the unit, detailing a number of concerns. Arising from this inspection. It was also evident that the formal review of the care of service users, (involving significant professionals, family advocates and, where possible, the service user), was not happening with the required frequency. Service users PCP’s must be reviewed regularly, and at least every six months. The information contained in some of the communication passports, describing the methods by which individuals communicate their wishes, was very limited in some cases. The service users would benefit from a review of their communication strategies and abilities, by a speech and language therapist, with a view to expanding their individual repertoires and skills to enhanced their quality of life. It was noted that many of the care planning and other records were in handwritten form, sometimes hard to read, or open to misinterpretation. Best practice would be for these records to be typed and printed on computer. This also enables more efficient subsequent updating of the records. It is understood that the unit has yet to be supplied with a computer, which should be considered by the registered provider. DS0000011147.V272667.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14, 16, 17 Service users are, to a limited extent, part of the local community, and engage in some appropriate activities, but there remains room for further improvement in these aspects of their lives. The rights of service users are respected and there are plans to increase the level of individual responsibility within individual’s daily lives. There have been some developments in the provision of a healthy diet, though this remains an area for further development. EVIDENCE: As already noted each service user has an individual activity plan (apart from one which was missing from their file), but these documents are out of date and exhibit too much reliance on domestic and household chores defined as activities and insufficient reference to creative and other activities. In some cases where care plans indicated a particular interest, this was not reflected in the activity plan. There remains room for development of the
DS0000011147.V272667.R01.S.doc Version 5.0 Page 14 opportunities for service users to be a part of the local community and to access more external activities and events. One service user was allocated partial funding for two-to-one staffing to enable them to access more community-based activities, and the possibilities of horse-riding were being explored, together with swimming and possible access to the local Mencap-run sensory room. It was reported that all of the staff had recently attended training on Person Centred Planning and that keyworkers were going to develop the activity plans in consultation with the service users, their families, and the team. The manager must ensure that the activity plans for all service users are reviewed to further improve the level and range of activities, and ensure they rely less on household tasks. Any identified religious affiliations should be reexplored to establish whether individuals may wish to attend services. There was a noticeable improvement in the level and quality of interaction with service users by staff during this inspection, with more proactive approaches to individuals and generally more attentive practice in evidence, which was a positive development. Some additional provision for service user activities was evident within the unit. For example some art and craft materials were available at a table in the conservatory, and were observed in use by one service user. Staff do try to maximise the dignity of service users when providing personal care support by working behind closed doors. Staff will knock on bedroom doors before entering. Service users can move freely about the unit and can choose to spend time alone or with the group. The manager has already begun to review some of the previous behaviour management plans to try to find more creative responses to some behaviours by individual service users. As already noted there has been considerable emphasis on involvement in household tasks being seen as activities. It is appropriate for service user involvement in household tasks to be encouraged and supported, in order to develop their skills and abilities, as long as these tasks are not disproportionately represented within their range of ‘activities’. For example the manager is considering the provision of raised beds and sensory planting in the rear garden to try to enhance service user involvement in the garden. The manager has begun to introduce an emphasis on healthier diet and will be developing the level of service user involvement in menus. The lunchtime meal DS0000011147.V272667.R01.S.doc Version 5.0 Page 15 was a good example of this improvement, being a very tasty home-made soup with bread and butter, followed by yoghurts or fruit. It is good to see a move away from processed foods which were a significant part of the previous menu. Further improvements in this area could be made, and the level of service user involvement in meal preparation could be improved, within the context of appropriate risk assessments. Some of the service users require a degree of assistance or encouragement at mealtimes and this is made harder by the cramped layout of the dining area, and the staff therefore often have to stand over service users when assisting them, which is not best practice. DS0000011147.V272667.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 From the available records it was not possible to establish whether service users receive personal care support in the way they would prefer it. It was also not possible to establish that service user’s physical and emotional health needs are fully met, from the available records. EVIDENCE: Service user’s individual preferences around their care and support are recorded within their Person Centred Plan (PCP). However, as already noted, some of this information is old and not recently reviewed. As already noted these documents require complete review to ensure they reflect the current needs and wishes of service users. (Requirement made under Standard 6). The unit aim is to provide same gender care, although there are times when this has not been possible. Despite a lack of permanent male staff, the manager has usually been able to address this issue via known agency staff, familiar to the service users. DS0000011147.V272667.R01.S.doc Version 5.0 Page 17 Examination of the health-care plans indicated that these were either not being maintained up-to-date, or there have been long gaps between periodical appointments such as dentist, chiropodist, optician etc. In one case the most recent entry for contact with a dietician was 6/02, despite there being recorded concerns on their file about weight gain. There were no specific dated records of chiropodist visits, since 2/01, although the chiropodist visits the unit regularly, and no records of speech therapy appointments since 11/01 in one file. Other records were undated, for example a detailed visual assessment audit on one service user. If documents are undated, it is difficult to monitor the regularity of appointments and assess whether the needs of the service user are being met. All records on file must be dated and signed by the author. The manager reported that she planned to develop individual health action plans in liaison with the Health Facilitator. The healthcare aspects of individuals care records must also be maintained up to date along with their other care records. (Requirement made under Standard6 above). DS0000011147.V272667.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 It was not possible to establish that concerns raised by service users would be addressed, as there were no such recent entries in the complaints log. Recent entries relating to complaints by neighbours about noise, had however been addressed appropriately. The degree to which service users are protected from abuse, is compromised by the absence of whistle-blowing training and the need for additional staff to receive training on behavioural awareness. EVIDENCE: The unit has a written complaints procedure, but a previous requirement to produce a version more accessible to service users had only partially been addressed. The previous manager had produced a version in symbol and picture form, but it was not clear that this would meet the needs of the service users in the unit. The new manager reported that another Milbury unit manager was working on an adapted version of the procedure and she was awaiting this, and would adapt it to meet the needs of the unit. Further work on the communication strategies of service users would be beneficial in enabling them to raise any concerns they might have. The complaints log indicated no new complaints since 13/7/04. Recent previous complaints related to noise nuisance and came from neighbours. Each individual entry had been countersigned by the operations manager, but there were no dates attached to the signatures. It is suggested that it would be
DS0000011147.V272667.R01.S.doc Version 5.0 Page 19 good practice to countersign and date the log monthly to evidence the required monthly Regulation 26 monitoring. The unit has a written procedure for the protection of vulnerable adults and also a copy of the local multi-agency vulnerable adults protection protocol. All of the staff have attended Protection Of Vulnerable Adults training, (provided internally), although no whistle-blowing training has yet been attended. However, there has been team discussion of whistle-blowing, arising out of the previous issue of inappropriate restraint of one service user, which did not generate any expressions of concern to management at the time. The new manager has since discussed the issue with the appropriate authorities, and the agency who supplied the staff member. All staff should attend whistle-blowing training as a priority. The training spreadsheet also indicates a need for a number of staff to attend the behaviour awareness training. (Requirement made under Standard 35). DS0000011147.V272667.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 The environment provided to service users continues to fall below an acceptable standard of décor, in several areas, despite previous inspection requirements. Whilst it is comfortable, this too, is compromised by the lack of appropriate window dressings in the lounge and conservatory. There are health and safety concerns regarding the standard of cleanliness in the kitchen, the toilet flooring and the rear garden patio. EVIDENCE: The bedrooms were the most pleasantly decorated rooms in the unit, and each was individualised to reflect its occupant. It is proposed to replace the carpets in two of the bedrooms with suitable vinyl with the agreement of the service user and their families. A previous requirement to review the unit fire risk assessment had not yet been carried out and should be addressed promptly as it is a health and safety issue. A further previous requirement to redecorate the communal areas to bring them up to an acceptable standard of décor had also not been addressed. The
DS0000011147.V272667.R01.S.doc Version 5.0 Page 21 lounge remains in a shabby state of decoration, with patches of filler and a missing curtain rail and curtains, and the dining room was also very shabby. The conservatory was also in need of some sort of blinds or curtains. It was, however, positive to see a table set up in the conservatory for art and craft activities, and being used, which was a new development. The kitchen walls were dirty, greasy and in need of a deep-clean and redecoration. In its current condition, the kitchen could present a health hazard and this must be addressed as a priority. The fridge was still missing its door handle. The bathrooms also needed repainting to cover previously observed written instructions to staff. The toilet flooring was also lifting at the edges and presents a further potential hazard. In the rear garden, some work had been done to address the subsided area of patio, but this had not been done properly and some paving remained uneven or rocked when walked upon. This must be repaired properly. Appropriate consultation should take place with the environmental health authority regarding the health and safety issues identified. The manager has plans to provide sensory planting and raised beds in order to encourage greater use of the garden by service users. Some spring bulbs and other planting had already been placed in the borders in the front garden, which would soon enhance this rather barren area, which is entirely turned over to staff parking. The manager had already arranged for some Newbury day centre uses to carry out some garden works and the rear garden already looked more presentable. DS0000011147.V272667.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 36 The service users are supported by a staff team that is more effective and consistent in approach than previously, and is composed of a greater proportion of permanent staff. Service users are protected by an improved recruitment practice, and benefit from a more motivated and better supported staff team than previously. EVIDENCE: The manager has set the required staffing at a minimum of four staff throughout the waking day, until 8pm, to enable greater focus on supporting the service users in accessing facilities and activities in the community, for which some require two-to-one staffing. Night staffing is one on waking night duty and one sleeping-in. There has been some success in attracting new staff to fill vacant posts, with four full-time and one part-time post having recently been recruited to. There have also been other staff come and go since the previous inspection. One senior support worker, and three support worker vacancies, had also been recruited to, and were awaiting recruitment checks. This leaves only about one and half vacant posts.
DS0000011147.V272667.R01.S.doc Version 5.0 Page 23 This is a positive situation for a unit where recruitment has previously been difficult, possibly due to its location. The manager has introduced monthly staff meetings, and detailed minutes were in place to demonstrate these. The recruitment records for three of the recent recruits were examined and found to be comprehensive apart from one missing reference copy, which the manager undertook to obtain from head office. The manager had provided supervision to the staff in December, but prior to this the last ones had been in September/October. The manager plans to establish monthly supervision and encourage the input of supervisees to their supervision. Written records are kept and staff receive a copy, which is good practice. It is proposed to share the supervision between the manager, deputy and the senior, once both are in place and have completed their supervision training, booked in February. DS0000011147.V272667.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42 At present there is no systematic method for seeking the views of service users about the service they receive, and the quality assurance system requires further development to attempt to address this. Systems for annual review, and development planning have yet to become fully established including the provision of required copies to the Commission. The health and safety of service users and staff is potentially compromised by the apparent ongoing failure to carry out remedial works identified within the Legionella survey. EVIDENCE: A quality assurance report had been produced for 2004/5 and the manager undertook to forward a copy to the inspector. Questionnaires had been provided to relatives, care managers and day care services so far, for the latest round of the quality assurance cycle. The report had yet to be produced. A copy should also be forwarded to the inspector.
DS0000011147.V272667.R01.S.doc Version 5.0 Page 25 There is a need to seek an appropriate methodology to try to obtain the views of the service users themselves, perhaps via independent advocacy. There is also a need to produce an annual review of the care provided by the unit for 2005/6, and copy this to the inspector, together with an annual development plan for 2006/7. No evidence was available to confirm that a previous requirement to address necessary remedial works identified within the Legionella survey, had been addressed. This health and safety related requirement is outstanding from the previous two inspection reports. The remainder of Standard 42 was not examined on this occasion. DS0000011147.V272667.R01.S.doc Version 5.0 Page 26 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 1 X X X X X 1 LIFESTYLES Standard No Score 11 X 12 X 13 2 14 2 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 X X Standard No 37 38 39 40 41 42 43 Score X X 2 X X 2 X DS0000011147.V272667.R01.S.doc Version 5.0 Page 27 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 Regulation 15(2)(b) Requirement The care planning and documentation systems for maintaining service user records require updating. The registered manager must ensure that service user’s plans are regularly reviewed in line with the standard and at least at six monthly intervals. The registered manager must consult, or otherwise work with, the service users in order to increase the range of opportunities for service users, both in the home and in the local community The manager must ensure that a version of the complaints procedure, accessible to service users is made available in the unit. The Registered Person must provide to CSCI, copies of any investigation reports or correspondence relating to the identified series of restraints. The registered manager must ensure that all staff are provided with training on the whistleblowing policy/procedure.
DS0000011147.V272667.R01.S.doc Timescale for action 18/03/06 2 YA13 16(m) 16(n) 18/04/06 3 YA22 22(2) 18/03/06 4 YA23 37(e), 37(g) 18/02/06 5 YA35 13(6) 18/04/06 Version 5.0 Page 28 6 YA24 23(4)(a) 7 YA24 23(2)(b), (d), (o) The registered person must review and update the unit fire risk assessment. The registered person must consult with the fire authority where necessary. The registered person and the registered manager must ensure that appropriate refurbishment, cleaning, repair and decoration are undertaken in respect of the areas identified in the report. i.e. kitchen, communal areas, toilet and patio. 18/03/06 18/03/06 8 YA24 23(5) 9 YA39 24(3) 10 YA39 24(2) Aspects of this requirement remain outstanding from the previous inspection. The registered person and 18/02/06 registered manager must consult appropriately, and where necessary, with the local environmental health authority on any of the matters listed in requirement 7. The registered person and registered manager must devise 18/04/06 an appropriate system for seeking the views of service users about their service, as part of the Quality Assurance system. The registered person must 18/04/06 supply copies of the identified annual review, quality assurance and annual development plans to CSCI. This requirement remains outstanding from the previous two inspections. The registered person must address the identified remedial works within the Legionella survey report. This requirement remains outstanding from the previous two inspections. 11 YA42 13(3) 18/03/06 DS0000011147.V272667.R01.S.doc Version 5.0 Page 29 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 YA22 Good Practice Recommendations The registered manager should consider arranging a review of the communication repertoire of each service user by a speech and language therapist. The Regulation 26 visitor should consider countersigning the complaints log to evidence their monthly monitoring. DS0000011147.V272667.R01.S.doc Version 5.0 Page 30 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 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 DS0000011147.V272667.R01.S.doc Version 5.0 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
