Inspection on 26/03/07 for 32-33 Macarthur Road

This inspection was carried out on 26th March 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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

32-33 Macarthur Road 23/01/09

32-33 Macarthur Road 05/12/07

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 32/33 Macarthur Road 32-33 Macarthur Road Northleach Cheltenham Glos GL54 3HS Lead Inspector Mr Richard Leech Key Unannounced Inspection 13:00 & 26th & 27th March 2007 11:15 32/33 Macarthur Road DS0000066773.V334484.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 32/33 Macarthur Road DS0000066773.V334484.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. 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 32/33 Macarthur Road Address 32-33 Macarthur Road Northleach Cheltenham Glos GL54 3HS 01451 860237 F/P 01451 860237 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) www.brandontrust.org The Brandon Trust To be Appointed Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23/02/06 Brief Description of the Service: Macarthur Road consists of two semi-detached houses connected to each other on the ground floor. The home is in the village of Northleach in the Cotswolds. Transport is provided to enable people to access different activities. People using the service have single rooms either on the first or ground floor and also have access to a range of communal areas including two adjoining lounges. Up to date information about fees was not obtained during this inspection. 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began at 1pm on a Monday afternoon, lasting until midevening. A second visit was made on the following day from about 11am to late afternoon. A number of the staff were spoken with and the manager was present on the second day. Over the course of the inspection all of the service users were met. Following the inspection some survey forms were sent to different people with an interest in the service, including relatives and health & social care professionals. Some survey forms were also sent to members of the staff team who were not met during the inspection and also to each of the service users to give them an opportunity to offer further feedback if they wished to. Various records were examined during the inspection. These included samples of care plans, risk assessments, medication charts, staffing files and information about training. Some discussion took place with a visitor to the home. Some periods of general observation also occurred in the communal areas to give an indication of daily life and interactions in the home. What the service does well: A good approach to admissions means that people who move to the home can be confident that the service will assess and meet their needs. The standard of care planning is good. Systems for assessing and managing risk are also generally good, with people being supported to take risks as part making choices about their lives. People living in the home are supported to lead lifestyles which reflect their needs and interests, and to maintain contact with family and friends. Menus are flexible and balanced and reflect people’s choices and preferences. Service users receive the support that they need to stay well and to look after themselves. People who use the service are supported to take forward concerns and complaints, helping to make them feel valued and listened to. They are offered meaningful choices, helping them to feel in control of their lives. There is a good approach to using different communication methods according to each person’s needs. Staff are skilled and caring. Service users are becoming involved in helping to select new staff to work in the home. 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 6 Systems are in place which help to monitor and improve the quality of the service. This includes consulting with people living in the home. What has improved since the last inspection? 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. 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 7 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 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 8 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. A good approach to admissions means that service users moving into the home and others involved in their care can be confident that their needs will be assessed and met. EVIDENCE: Standard 1 was not checked. However, there was a discussion with the manager about the Statement of Purpose and Service Users Guide. The manager was not able to locate the documents and reported that these had not been reviewed since he became the manager (and possibly since the Brandon Trust became the service providers). They were therefore in need of review and revision. In addition, the manager stated that two service users who had moved in during the previous few months had not received copies of the Service Users Guide. In previous reports for other Brandon Trust homes it has been recommended that the admissions policy dating from 2000 be reviewed and updated. The Trust has indicated that a full review of policies and procedures will take place, to be completed by September 2007 at the latest, with reviews then taking place annually. 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 9 As indicated, two service users had moved in since the last inspection. Records relating to their admission were checked and the manager and staff were asked about the admission process. Both service users were also met. In both cases it was found that the team had made appropriate efforts to obtain background information and assessments and to conduct their own assessments of need. The two people had also been offered opportunities to visit the home before moving in, with some write-ups of these visits being made. It was agreed that although the timing was not ideal in terms of ongoing difficulties with staffing levels (see later sections of the report) the admissions appeared to be appropriate in terms of the range of the needs that could be met by the service. 32/33 Macarthur Road DS0000066773.V334484.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst a good care planning framework is in place, some recent slippage with reviews and updates may result in people’s care plans not keeping up with their needs, goals and wishes. Systems for risk assessment and management also need to be kept up to date so that people are as safe as possible whilst being enabled to pursue their interests and wishes. People living in the home are offered meaningful choices, helping them to feel empowered. EVIDENCE: Care plans for four people were checked. These were seen to cover appropriate areas such as personal care, likes & dislikes, communication issues, eating & drinking, relationships and activities. Whilst the content was generally clear and person-centred the process of review and update had begun to falter. For example, some care plans were recorded as having last been reviewed in February 2006 or as far back as June 2005. Some documents were undated. 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 11 However, in other cases more recent reviews had taken place, with documented input from the service user and from a range of other people involved in their care in the home and community. Some staff spoken with also felt that care plan reviews had not been as frequent and thorough as they should be recently, related primarily to being short-staffed. There was some feeling that, as a result, the team was not being sufficiently proactive in helping people to identify goals (including to move on) and to maintain and develop skills as they could be if the care planning system was functioning as it should. Whilst there was no direct evidence of an impact on the outcomes for service users it is strongly recommended that this be addressed. Many care plans were in alternative formats in order to make them more accessible. There was evidence throughout the home of a strong emphasis on total communication in order to promote service users’ understanding and involvement. A visiting professional commented on the home’s good approach to total communication. Care plans were also seen to include reference to promoting choice and independence. In some cases there was detailed information about people’s preferences, such as around personal care routines. Observation and daily records provided evidence that people living in the home were offered choices in daily life such as around daily routines and diet. Service users spoken with gave examples of being offered and making choices, such as about the menus, their activities, making drinks and going out independently. Some best interests work was taking place, for example around significant health issues. It was agreed that the licensing agreements from the Housing Association should also be subject to the best interests process in some cases. Certain restrictions were seen to be documented in care planning files and to be related to risk management and people’s best interests. Risk assessments seen appeared to provide appropriate guidance about risks and their management, and to weigh up the potential risks of an activity against the benefits. The emphasis was seen to be on the supporting service users to take appropriate risks as part of leading full, socially included lives. Guidance from external professionals had been included where appropriate. As with care plans however there was some evidence that reviews were beginning to slip. For example, one risk assessment about going alone to the local village was recorded as last being reviewed in June 2006. It is important that risk assessments remain up to date as part of the service’s responsibility to assess and manage risk issues as they evolve and change in accordance with people’s lifestyles, needs and wishes. 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 12 One person who moved in a few months prior to the inspection had one risk assessment in place. Another person had moved in just a few days before the inspection. However, it was clear that some urgent work would need to begin on interim care plans and risk assessments in response to some significant issues which were already presenting. Staff described how they assessed and managed risks on a day-to-day basis, providing evidence of a supportive and empowering approach. Service users were observed going out to the village on their own and describing day-to-day activities which involved risks but which formed part of their chosen lifestyle. A missing person’s procedure was seen on the office wall, accompanied by photos of service users. However, the two people who had recently moved in were not included and also the procedure had contact details for the previous manager. 32/33 Macarthur Road DS0000066773.V334484.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, & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are supported to take part in individualised activities in the home and community and to maintain contact with family and friends, promoting their quality of life. Routines in the home are flexible and person-centred, helping service users to feel in control of their lives. Menus are flexible and balanced and reflect people’s preferences, enhancing service users’ enjoyment of mealtimes and their general wellbeing. EVIDENCE: Care plans made reference to activities and interests. Examples of activity programmes were seen. Efforts had been made to translate these into an accessible format. Daily diaries for a 10-day period for three people were checked. These provided evidence of people taking part in varied and 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 14 individual activity programmes in the home and community. This included some activities in the evening such as trips to pubs and social groups. People living in the home were observed going to and coming back from different activities. Some people were asked about their activities and indicated that they were happy with how they spent their time. Staff felt that service users’ led full lives and that they were generally satisfied with their activities. Some staff felt that there were areas where activity provision could improve, related in part to the ongoing difficulties with staffing levels. The manager echoed this, and felt that programmes would become fuller and more individualised once the staffing situation was resolved. Care plans were seen to include how people were supported to maintain family contact. There was also guidance about other relationships where appropriate. Daily records viewed included frequent reference to contact with family as did activity timetables. A phone was available in the home for the people living there to make or receive calls from family and friends, with the main house phone also used at times. Staff were seen supporting people to speak with relatives. Care planning files included information and contact details about important people in service users’ lives. A survey form from a relative included the comment, “I think they do a good job in every way”. Observation, care plans and daily records provided evidence that routines in the home were flexible and based around people’s needs and preferences. As noted, people were seen going out on their own where appropriate. Service users were also observed choosing where they spent their time and with whom, such as on their own in their rooms, relaxing in the lounge or helping with the cooking. Staff described some conflict issues between people living in the home and how these were handled. Observation suggested that some conflict issues which were presenting in relation to a person who had just moved in may require care planning. Records and observation provided evidence of service users being consulted about meals and menu planning, as well as being involved in cooking and food preparation. Discussion with staff and with people using the service provided further evidence for this. Service users expressed satisfaction with the food served in the home. Some people were taking courses on cooking as part of their activities programme. Staff confirmed that people could have alternatives to what is on the menu if they wish, and were heard discussing this during a handover. Menus viewed were imaginative and appeared balanced. A meal was observed. The food was well presented and people seemed to be enjoying their food. 32/33 Macarthur Road DS0000066773.V334484.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 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are enabled to access appropriate healthcare and are offered necessary support with personal care, promoting their wellbeing. However, some shortfalls in the handling of medication and associated records may begin to compromise service users’ safety if not addressed. EVIDENCE: As noted, care planning included reference to how people would be offered personal care support, with detail given about their routines and preferences. Staff spoken with described how they offered this support, providing evidence of an approach where people’s privacy, dignity and wishes were respected. At the time of the inspection a change of policy about personal care was being considered such that male staff could support some female service users with personal care where consultation had taken place and this had been agreed. The manager said that there was not a policy about personal care support in place. The policies and procedures file was checked and no such policy was found. It is recommended that a policy be written covering this area. 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 16 General observation provided evidence of personal care support being offered in a discreet and sensitive manner. People were dressed smartly and individually and in some cases expressed pride at their appearance. Healthcare records for two service users were checked. These provided evidence that people living in the home were supported to access routine and specialist healthcare as required. Staff described how they ensured that this happened. The manager agreed that the next step in this area should be the implementation of health action planning and the more comprehensive and proactive approach that this entails. The service has a policy about medication dating from 2000. An up to date BNF (a reference manual about medications) was available in the home. Staff spoken with confirmed that they are required to undertake a distance learning course about the handling of medication, as well as receiving in-house training, before they are able to administer medication to people living in the home. Medication storage appeared to be in order, although some medication which needed to be disposed of one month after opening had not been marked with the date when opened. This was done during the inspection. The majority of medication administration records seen were in order. However, the manager pointed out that an error had taken place on 24/03/07, with some people’s medications having not been given. Following the inspection a formal notification was received about this error. Recent regulation 26 reports and notifications have included reference to medication issues. On 25/01/07 it was reported that one person’s morning medication was missed. On a report from November 2006 gaps were found in one person’s medication administration record. The above indicates that greater vigilance is necessary and that training or revisiting of procedures may be required. The formal notification about the recent error included some measures which the manager was proposing in order to improve practice. There is a ‘medication given’ check on the handover sheet though this was seen to be inconsistently completed. One person was prescribed a cream the administration of which was an intimate personal care procedure. The (male) manager had initialled the medication administration record on one occasion in March 2007, but said that the medication had been administered by a female care worker. In law the person who signs has administered. This is an example of poor practice and should not happen. The manager pointed out that money tins were being stored in the medication cabinet as there was no suitably secure alternative. It is recommended that an appropriate alternative be put in place, such as through fitting a safe. 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 17 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 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to take forward concerns and complaints, helping to make them feel valued and listened to. Poor practice in the handling of people’s finances places them at risk of being out of pocket. EVIDENCE: The Trust has a complaints procedure. It is understood that this is to be reviewed and should then become more accessible/user-friendly. The complaints log was seen. This provided evidence of people using the service being supported to raise issues and of these being handled appropriately. Notifications to CSCI have also included details of investigations in response to service users’ complaints. The service has a whistle blowing procedure, as well as a policy about safeguarding adults dated December 2005. This included reference to the ‘No Secrets’ document. Staff spoken with demonstrated awareness of adult protection issues and of their responsibilities in this area. However, they reported that there had been no recent training about adult protection and prevention of abuse. 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 18 Financial records for four service users were looked at for the month of March 2007. All of these records contained errors/discrepancies, with cash balances either being up or down in relation to the written running total. In at least one case it appeared that the person may have lost out financially since an 80p shortfall seemed to have been written off on 10/03/07, when a balance check was done and the total was recorded with no reference to the shortfall previously identified. This level of discrepancies suggests that greater vigilance and checking are required. An audit must be completed, going back as far as necessary, and any service users found to have lost out financially must be refunded. The manager agreed that the above findings were unacceptable and described plans to change the system for handling service users’ finances. 32/33 Macarthur Road DS0000066773.V334484.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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although a homely, comfortable and clean environment is generally maintained some shortfalls impact on service users’ safety and the overall quality of accommodation. EVIDENCE: All communal areas were checked along with some service users’ bedrooms at their invitation. In general there was a comfortable and homely atmosphere with satisfactory décor. Service users spoken with mostly expressed satisfaction with their rooms and other areas of the home. However, the following was noted: • • Several fire doors needed attention because their self-closing mechanisms were broken or the intumescent strips missing. The fire door between the two adjoining properties was propped open. This needs to either be closed or a self-closing mechanism linked to the fire alarms fitted. DS0000066773.V334484.R01.S.doc Version 5.2 Page 20 32/33 Macarthur Road • • • • • The main kitchen was in a poor state of repair. Some of the doors on the units were lop-sided and did not close properly and some of the drawer fronts were coming off. The door on one unit was missing altogether, presenting a hygiene risk. One cupboard containing hazardous chemicals was locked but the state of the door panels was such that the chemicals could still be accessed. Parts of the kitchen therefore need repair or complete replacement. The light bulb in the main fridge in the kitchen was not working. This should be replaced. A carpet in one of the lounges had a burn from an iron. The team should consider replacing this. Some staff felt that work could be done to make certain bathrooms and toilets more homely and inviting. This idea should be considered in consultation with service users. One person who had moved bedrooms about six months before had requested at the time that the décor in their new room be changed. This should be taken forward. The home appeared to be clean throughout. A visiting professional said that the home was always welcoming, clean and fresh in their experience. 32/33 Macarthur Road DS0000066773.V334484.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 & 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are skilled and caring, helping to ensure that service users’ needs are met, although short staffing and resultant cover arrangements are impacting on some areas of the quality of the service. Recruitment and selection practices provide protection for service users. An inclusive approach helps to make the people living in the home feel involved in the process. Some areas of training provision for staff require significant attention in order to promote service users’ safety and wellbeing. EVIDENCE: Service users spoken with were positive about the staff team. One person said that the staff were ‘good quality’. Observations provided further evidence of staff being skilled, caring and sensitive to people’s needs, and this was backed up by comments from a healthcare professional in a survey form. Staff spoken with demonstrated a good understanding of the needs of the people living in the home. A visiting healthcare professional gave feedback about the staff 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 22 working and communicating well with the community team and carrying out recommendations. Staffing files provided evidence that 50 of the staff team had attained NVQ level 2 or equivalent/higher. Due to ongoing short staffing many of the people supporting service users around the time of the inspection were bank or agency staff. Inevitably their knowledge of the service users’ needs and routines will be less than that of the permanent care workers, although staff confirmed that efforts are made to ensure that the same people return to the home to provide some continuity. Discussion with the manager, staff and service users as well as inspection findings noted elsewhere in the report provided evidence of the impacts of short staffing. One service user said that the home needed more staff. Permanent team members spoken with indicated said that staff were having to work very hard and that some areas had slipped a little, such as care planning and activities. Some expressed concern about the pressure increasing the risks of mistakes being made, such as in medication administration, and there were comments on supervision being too infrequent in some cases. The manager said that the home was ‘very short staffed’, but that further interviews were taking place that week in an effort to address this. He said that, with the home now being full, it was intended that more staff would be on shift at certain times, particularly at weekends. There had been no new staff employed in the home in the last 12 months besides the manager. Staffing files were therefore checked only for training records. The recruitment and selection process was described, including appropriate safeguards to protect service users. The manager and deputy said that a person living in the home had been invited to join the panel for the forthcoming round of recruitment. The service user confirmed this. Staff were observed planning how to help the person to prepare for this and to seek the input of other people living in the home. As with all services, evidence of actual practice will be checked during future inspections to ensure that appropriate procedures have been followed. Training records for selected staff revealed that certain areas of basic training were overdue for some or all staff. This included food hygiene, fire safety, first aid and moving & handling. Staff spoken with confirmed that training had slipped recently to the point where refreshers were overdue. Suggestions were made about further training that may benefit the team, such as about person centred planning, autism, and the Mental Capacity Act, once core training was up to date again. Some people felt that, once the staffing situation was resolved, some team building time would be helpful in order to promote cohesion and motivation. 32/33 Macarthur Road DS0000066773.V334484.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service is not being run as well as it could be, which may begin to impact on service users’ quality of life and safety if not addressed. Systems are in place which help to monitor and improve the quality of the service. Some aspects of health and safety in the home need attention in order that service users are as safe as possible. EVIDENCE: At the time of the inspection the manager had been in post for about four months. He reported that he had not yet changed much in the home as he was still learning about how it operated and where improvements could be made. 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 24 The short staffing was also impacting on this and he anticipated being able to devote more time to management rather than hands-on care in due course. The manager had not yet registered with us at the time of the inspection. This will need to be done as soon as possible. In terms of the overall running of the home, as noted in other sections of the report, certain areas such as training have experienced slippage and this will need to be addressed. Quality assurance in the home was considered. Regulation 26 reports have been received about the service about once a month. Records of residents’ meetings were seen, indicating that there was wide-ranging and inclusive discussion. Another meeting was planned for one evening of the inspection. The Trust has a series of core standards. In 2006 their services were expected to undertake a self-audit against these. In Macarthur Road this had been done in October 2006, before the new manager was in post. The manager was not sure what was meant to happen with this audit. It is recommended that it be reviewed and the findings incorporated into an action plan which the manager had written independently (a copy of which will be forwarded to CSCI). The manager described some of his main priorities as outlined in his action plan. Some basic health and safety records were checked including fridge & freezer and hot water temperatures, vehicle checks and the fire logbook. These were satisfactory. Portable appliances were checked in July 2006. A system of monthly walk-around checks had been in operation until November 2006 but had then ceased. The manager indicated that he would reinstate this. Staff reported that the routine servicing of fire equipment was overdue, adding that this had been reported to the housing association on 04/02/07 but had not yet been addressed. As noted, some areas of basic training have lapsed, with implications for people’s health and safety. Some of the fire doors also need attention. Potentially hazardous chemicals were accessible in the kitchen. 32/33 Macarthur Road DS0000066773.V334484.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 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 2 x 2 x 3 x x 2 x 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 YA1 Regulation 4&6 Requirement Review and update the Statement of Purpose as appropriate. Review and update the Service Users Guide as appropriate. Supply a copy of the Service Users Guide to each person using the service. Ensure that the person who signs the medication administration record is the staff member who actually administered the medication. An audit of service users’ finances must be completed, going back as far as assessed to be necessary. Any service users found to have lost out financially must be refunded. Ensure that all fire doors are appropriately maintained and fit for purpose. The fire door between the two adjoining properties needs to either be kept closed or have a self-closing mechanism linked to the fire alarms fitted. 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 27 Timescale for action 16/07/07 2 YA1 5&6 16/07/07 3 YA20 13 (2) 30/04/07 4 YA23 12 (1). 17 (2). Sch. 4 (9) 18/06/07 5 YA24 23(4) a 31/05/07 6 YA24 13 (3), 16(2) h & 23 (2) b. 13 (3), (4) & (5). 18 (1) c (i). 23 (4) a. 7 YA35 Ensure that the kitchen is in a 31/08/07 good state of repair, safe for use by people living in the home and hygienic. Staff must receive training 31/08/07 appropriate to the work performed, including training in first aid, food hygiene, fire safety and moving & handling. 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 Good Practice Recommendations Re-establish a comprehensive system for reviewing and updating care plans, involving service users, in order that people’s assessed and changing needs and personal goals are consistently reflected in their care plans. The licensing agreements from the Housing Association should be subject to the best interests process where necessary. Update the missing person’s procedure and accompanying photo cards as noted in text. Ensure that risk assessments are kept as up to date as possible. A policy covering principles and issues around personal care support should be in place. Implement a system of ‘Health Action Planning’ in consultation with appropriate healthcare professionals. The ‘medication given’ check on the handover sheet should be consistently completed. Following investigations into the recent errors with medication records or administration, consider the reasons and identify whether any action is required, such as training or competency assessment. Consider providing a safe in order that money no longer needs to be stored with medication. Training about adult protection and prevention of abuse should be provided for the team as part of the overall approach to safeguarding people using the service. • The light bulb in the main fridge in the kitchen should be replaced. DS0000066773.V334484.R01.S.doc Version 5.2 Page 28 2 3 YA7 YA9 4 5 6 YA18 YA19 YA20 7 8 YA23 YA24 32/33 Macarthur Road 9 YA39 Consider replacing the carpet in one of the lounges with an iron burn. • Consider whether work could be done to make certain bathrooms and toilets more homely and inviting. • Arrange for service users who would like the décor in their rooms changed to have this taken forward. Review the audit based on the Trust’s core standards completed in October 2006 and incorporate the findings into the home’s action plan. • 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 32/33 Macarthur Road DS0000066773.V334484.R01.S.doc Version 5.2 Page 30 - 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. 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