Inspection on 20/11/07 for 46 Severn Avenue

This inspection was carried out on 20th November 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

46 Severn Avenue 03/11/08

46 Severn Avenue 29/05/07

46 Severn Avenue 26/05/06

46 Severn Avenue 08/02/06

46 Severn Avenue 20/12/05

46 Severn Avenue 05/10/04

46 Severn Avenue 25/05/04

46 Severn Avenue 13/01/04

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 46 Severn Avenue Weston Super Mare North Somerset BS23 4DQ Lead Inspector David Smith Key Unannounced Inspection 20 November and 5th December 2007 09:45 th 46 Severn Avenue DS0000008130.V348689.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 46 Severn Avenue DS0000008130.V348689.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. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 46 Severn Avenue Address Weston Super Mare North Somerset BS23 4DQ 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) 01934 626731 0117 9699000 david.rogers@brandontrust.org www.brandontrust.org The Brandon Trust David Rogers Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 6 persons aged 30 years and over Date of last inspection 29th May 2007 Brief Description of the Service: Severn Avenue is operated by The Brandon Trust and is situated in a pleasant suburban area of Weston-super-Mare. The home provides support for up to 6 service users with varying degrees of learning disability. Fees are negotiated with the placing authority. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the home as part of a Key Inspection of this service. The review of evidence and pre-inspection planning involved reviewing the report of the last Key Inspection carried out in May 2007 and the service history, which details all contact with the home including notifications of significant events which they have reported to us. We (the CSCI) provided the home with their Annual Quality Assurance Assessment (known as an AQAA, pronounced as ‘aqua’) and a range of survey forms for service users, their relatives, carers, advocates and health professionals, prior to my visit. The AQAA was completed and returned together with ten surveys. I gathered additional information during my visit through informal discussions with service users and Support Workers. Interaction and communication between staff and service users was also observed during my visit. Care plans and associated records were examined together with accident and incident reports, Risk Assessments, complaints procedures and health and safety records. I was also provided with a tour of all communal areas of the home and some of the service user’s own rooms. This Key Inspection process was concluded with a meeting on 05/12/07 between us and two staff members from The Brandon Trust who are currently sharing management duties at Severn Avenue during the Registered Manager’s absence. What the service does well: Each service user spoken with, and those who responded by survey, said they liked living in the home and were generally happy with the service they receive. The relatives who responded by survey said the home ‘usually’ meet the differing needs of each individual and provides the care and support they expect. A core of experienced staff remain who are enthusiastic about their work and are committed to providing a good service to each person who lives in the home. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 6 The organisation remains committed to providing training opportunities for the team to ensure they have the skills and abilities to provide appropriate support to each person who lives in the home. What has improved since the last inspection? What they could do better: The Statement of Purpose and Service Users’ Guide must be updated to accurately reflect the ethos, services, systems and procedures in place within the home. This will provide service users with up to date information regarding this service. Each service user should have their contract of residency explained to them so that they are aware of their rights and responsibilities whilst they are living in the home. The improvements in both the care planning and review processes must be completed for each service user. This will ensure a consistent approach in supporting each person. The Risk Assessment processes must be reviewed and improved. This will ensure safe working practices are present within the home to ensure the welfare of service users and staff. All concerns or complaints must be clearly recorded, together with details of the investigation process and outcomes. This will ensure service users’ views are listened to and acted upon and their safety and welfare is ensured. The frequency of staff supervisions should be improved to support them in providing a good quality service to each person who lives in the home. The frequency of service users’ meetings should be improved to ensure their views are central to the monitoring and development of the service. Fire safety within the home must be improved. This will promote the welfare and safety of people who live and work in the home. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 7 Organisational monitoring and support of the service needs to improve. This will help promote the safety of service users, improve service delivery and support the management team within the home. 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. 46 Severn Avenue DS0000008130.V348689.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 46 Severn Avenue DS0000008130.V348689.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): 1 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are not provided with sufficient information to enable them to make an informed choice about where to live, or the terms and conditions of their stay. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home has both a Statement of Purpose and a Service Users Guide. I examined the copies which were available in the home’s office on the day of my visit. Neither of these documents were up to date. The Service Users Guide contained sections referring to “The Care Standards Commission”, which had simply been crossed out and amended in pen to The CSCI. Both this guide and the Statement of Purpose are not dated, so it is not possible to ascertain when they were written or last reviewed. Service users’ care plans contained a copy of the Brandon Trusts’ contract, entitled “Places To Live Agreement”. These are written in plain English and have pictures to support the text, to help service users understand them. They have spaces for each service user’s name, picture, room number and the fees they are expected to pay in relation to accommodation and transport costs. I examined three of these contracts in detail, none had been completed fully and there is no evidence that their content has been discussed and agreed with the people who live in the home. There have been no new admissions to the home since 2001 and I therefore did not assess Key Standard 2, which relates to the assessment of prospective service users. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 11 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, 8 and 9. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is making efforts to ensure that the service provided to those that live in the home takes into account personal preferences and is supported by written information in care plans and risk assessments that are subject to ongoing review and improvement. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 12 EVIDENCE: Each service user has a care plan and I examined three of these during my visit. None of the plans I examined were easy to follow and the information in them varied greatly. One care plan remains in a ‘needs led’ format. The other two plans use the Trusts’ ‘Planning for Life’ format, although neither of these had all of the sections completed. This, combined with the amount of historical information, such as old review notes and goals, made them all very difficult to navigate and to know which information was current or which goals are still being worked towards. Each individual has been supported to set their own goals and aspirations, although the systems to monitor progress towards them remains unclear. For example one individual’s goal is to visit a relative every three weeks, though the records show the last visit as 21/1/07, with nothing recorded since. Another shows an interest in dog walking, though the only entry was noted as 4/05/08 (2008), so I could not ascertain if this had taken place at all. Each care plan I examined contained details of the last annual review attended by the service user, a representative from their Funding Authority and staff from both the home and Day Services, if this is appropriate. The Funding Authority had provided each person with a copy of their review notes. However, the review processes used within the home remain inadequate and inconsistent. One individual’s ‘Personal Plan’ was last updated in February 2007 with a note that the next review would take place during ‘Summer 2007’. There is no evidence to show this further review has taken place. Another individual’s care plan has not been dated at all, so it is not possible to ascertain if it is up to date, although the last review meeting appeared to have been held in November 2006. There is no evidence the care plan has been reviewed or updated since then. Each service user has a Keyworker and part of their duties is to ensure care records remain up to date. Keyworkers should complete a ‘Monthly Summary’ to provide an overview of each person, which should then be used as part of the review process. These are not being completed consistently. One service user last had a summary completed in December 2006 and another individual only had them completed for February and August 2007. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 13 The staff I spoke with did not seem clear on the review process they were expected to follow, what information should be used as part of this process and whether the service user is to be consulted at all. They felt that if this were ‘clearly explained to them’ they would be able to ensure this is done correctly, although it is not clear to me that it has been clearly explained to staff. As noted in the last inspection report, the involvement of the people who live in the home in making decisions about their lives and planning for the future remains questionable. It appears that service users are still discussed during staff meetings and decisions about them may be taken at this forum. The home used to support service users to hold their own meetings, where a variety of topics were discussed such as holidays, day trips, how to complain, menus and plans for the garden. The last meetings recorded are August 2006 and June 2007. It is not clear why these meetings have ceased. The records which are kept about the day-to-day lives of the people who live in the home still contain some language which is unprofessional and unclear. For example, one person’s records said they have “gone downhill” and “has been low”. Each individual does have person centred Risk Assessments in place which are designed to support them to take risks as part of their lifestyle. One person’s assessments were up to date as they were last reviewed in June 2007, although the two other individuals had not had their assessments reviewed since January 2006. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 14 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): 11, 12, 13, 14, 15 and 16. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are generally supported to develop, engage in appropriate leisure activities and access community facilities. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 15 EVIDENCE: Service users have the opportunity to attend sessions at local day centres and colleges. Facilities available in the wider community are also used including going out for drives and walks, trips to local pubs and cafes, shopping and horse riding. On the evening prior to my visit, service users had watched the ‘Carnival’ procession through Weston Super Mare and one person told me they really enjoyed it. On the day I visited two service users were at home and two were attending day centres. One person was supported to clean their room, and then went out shopping. A member of day services staff supported the other individual on a trip out of the house. The comments made earlier within this report regarding the lack of clarity in the support for individuals to develop or work towards their goals and how they are involved in determining their own lifestyle are equally relevant in this group of standards. The service users I spoke with and those who responded by survey said they were able to choose how to spend their day and generally were able to do the things they wished to do. Two service users said they did not feel they could do the things they wished during the weekends. Service users are supported to maintain regular contact with their family and friends and visitors to the home are welcomed. Staff have worked hard to ensure each service user is supported to choose, organise and attend a holiday. One individual showed me photographs of recent holidays, which they said they enjoyed. The relatives who responded by survey said they are kept up to date with important issues and felt the home does help their relative keep in touch with them. One relative said the home “looks after the residents and treats them as individuals” and another said “the care home does everything to make (my relative) happy, they are very concerned for his needs and do their upmost to fulfil them”. Observation during my visit and discussion with staff shows that each person who lives in the home is treated with respect and dignity. Each person is seen as an individual and treated as such. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users personal and healthcare support needs are generally met. EVIDENCE: The care documentation in place for service users is designed to provide clear guidance for staff on how they should support those living at the home with their personal care. However, due to care plans being out of date, not being clear or in the process of being transferred to ‘person centred plans’ the comments regarding care planning made earlier in this report are also valid here. The care plans I examined did show that individuals were registered with a GP of their choice. Other specialist services are accessed when an identified need arises. These are provided by the local Community Learning Disability Team (known as ‘CLDT’) and the home is supported by a Consultant Psychiatrist, Psychologist and other relevant health care professionals. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 17 The person centred care planning format contains a ‘health action plan’ although neither of the two care plans I examined which are in this format had this section completed. During the last inspection, it was noted that the home was viewed as reactive to the changes in the health of service users, rather than pro-active in health screening. I could find no evidence that this has significantly improved, although the quality of record keeping in this area is variable which makes this difficult to track effectively. Each care plan contains records of any contact with a healthcare professional, together with the outcome of the visit, which appear to be completed consistently. Other records such as the health risk assessment or health screening sections were not completed in any care plan I examined and the process of staff supporting service users to weigh themselves is haphazard. One service user has recently returned from a stay in hospital and another is currently admitted. The home has notified us of these admissions and it is clear from care records and discussions with staff that they visit service users regularly during their stays in hospital. The staff I spoke with did demonstrate a good knowledge of each individual’s support needs. Some people who live in the home have impaired communication skills and would rely on staff to identify and act upon any changes or concerns. I did not assess medication administration policies and procedures during this visit, however this was assessed during the last Key Inspection and was found to offer service users adequate protection. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users views are listened to and acted upon. They are protected from abuse, neglect and self-harm. EVIDENCE: The home has a formal Complaints Policy, an Adult Protection Policy and a Whistle Blowing Policy, which staff can use in confidence to raise any issue or concern they have regarding the service. The information provided on the home’s AQAA confirmed that there has been one complaint made during the last twelve months, although I could find no record of this during my visit. The service users I spoke with and those who responded by survey said they knew who to speak to if they were unhappy, although two people said they did not know how to complain formally. Each individual said that they felt safe living at the home and that staff ‘always’ or ‘sometimes’ listen to them and act on what they say. Most relatives who responded by survey said they do not know how to make a formal complaint, although they feel the home does respond appropriately if they raise any concerns about the care provided by the home. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 19 Staff are provided with training in relation to the Protection of Vulnerable Adults and are subject to Criminal Record Bureau enhanced disclosures before they start work in the home. There is very little ‘challenging behaviour’ displayed by people who live in the home and support plans contain guidelines which explain how to support individuals if they become distressed or present behaviours which may be perceived as challenging the service provided. The home maintains records of accidents and incidents. It also notifies us of any significant event which occurs within the home. 46 Severn Avenue DS0000008130.V348689.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, 27 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Severn Avenue provides a homely, comfortable and safe environment for service users to live in. EVIDENCE: Severn Avenue is a detached property situated in a pleasant suburban area of Weston-super-Mare. The garden area at the front and side of the house is paved, including a parking area for the home’s vehicle. There is a reasonably large rear garden, which service users are free to use. There are six single bedrooms, some on the ground floor and others on the first floor. None of the bedrooms offer en-suite accommodation, however there are sufficient communal bathrooms, showers and toilets which service users share. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 21 There is a communal lounge on the ground floor, a dining room, kitchen, entrance hall and lobby and one bathroom, which also contains a ‘walk in’ shower. On the first floor there is the laundry, one bathroom, a small office and the sleeping-in room which staff use. There have been a number of improvements since the last inspection. The window frames, which were mouldy and the rubber seals which were beginning to rot have been replaced. The mould has been removed from the ceiling in the upstairs bathroom, the flooring attended to and the broken seat replaced in the downstairs bathroom. The carpet in the downstairs corridor has been replaced. I did view some of the service user’s own rooms. These are all decorated and furnished differently to reflect the taste and choices of each individual. They contained many personal items, pictures and photographs which helped to make them personal to each individual. The service users I spoke with said they liked the home and felt they had everything they need in their own room. They did help keep the house clean and tidy. The service users who responded by survey said the home is ‘always’ kept ‘fresh and clean’. One relative who responded by survey said everyone “makes you feel very welcome when you go to visit” and another said “we are always made welcome”. The procedures in place for hand washing and infection control have been improved. There are now adequate hand washing facilities for staff in the laundry, kitchen and each bathroom area. 46 Severn Avenue DS0000008130.V348689.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): 31, 32, 33, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each person that lives in the home is supported by a staff team that is committed to providing a good service. The clarity of staff roles and responsibilities along with staff training and supervision are designed to provide a consistent approach to the support of staff and service users. EVIDENCE: There have been some significant issues relating to the staffing of the home since the last inspection. The Registered Manager has been on long-term sick leave since July 2007 and the Senior Support Worker, who would normally deputise in the Manager’s absence, has also been on sick leave from August to October 2007. To address these issues the organisation has asked a Senior Support Worker from another service to work at Severn Avenue on a full time basis, together with additional support from their line Manager. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 23 The staff I spoke with told me this had been a difficult time, but the support from the staff brought in has been very helpful. It was clear that staff had worked hard to ensure service users were affected as little as possible during this time. Each member of staff acts as a Keyworker to one service user. They also have a particular area of responsibility within the team, such as taking the lead on fire safety checks within the home. Staff said that the current ‘management team’ are trying to provide clear leadership in the development and improvements within the home. Staff also understand their own roles and accountability. Some staff members told me that although they feel their views are listened to, there have been many changes to cope with, such as service users being admitted to hospital, one individual moving to a new home, changes in start and finishing times of shifts and now sleeping-in rather than providing waking night cover. Some members of staff I spoke with felt that communication within the home could be improved, so that the changes may be managed better and they can then work more consistently. The staff team meets once a month. The records of these meetings show they are usually well attended, with a wide variety of topics discussed. I did note that the August meeting noted that there is “no team in this house, very little teamwork” which appears to support the views of some staff members I spoke with. Service users I spoke with said they liked the staff team and were well supported by them. Each service user who responded by survey said they are treated well by staff that generally listen to them and act on what they say. Relatives who responded by survey said the felt the staff ‘usually’ have the right skills and experience to look after people properly and support people to live the life they choose. The staff team are provided with a variety of training opportunities. The home now maintains a training matrix, which I examined. This shows that staff have attended training in First Aid, Manual Handling, Food Hygiene, Fire Safety and the Protection of Vulnerable Adults. However several members of staff do require the following refresher training. Six staff need to attend First Aid training, four staff require Food Safety training and four staff need Manual Handling training. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 24 Each member of staff has formal supervision sessions with their line manager. Although I did not examine their supervision records, staff told me they receive supervision approximately every six to eight weeks and they generally find this process helpful and supportive. The home does keep a separate list of supervision dates, which shows that staff were supervised in late August or early September 2007, with the next supervisions planned for November 2007. The AQAA states that improving the frequency of supervision is a goal and this appears important to ensure staff remain appropriately supported during this time of significant change within the home. Staff are supported to gain a National Vocational Qualification, known as an ‘NVQ’. The home has made good progress in this area and currently 70 of the staff team hold this award. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 25 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, 38, 39, 40, 42 and 43. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well run, however service users cannot currently be confident their views are represented and they would benefit from clearer leadership and management of the home. The home’s policies and procedures promote service user’s rights. The health, safety and welfare of the service users is not adequately promoted or protected. Service users are not provided with sufficiently competent or accountable management of the service. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 26 EVIDENCE: The Registered Manager, Mr.Rogers, is currently on long-term sick leave. The home is therefore now being managed by two Senior Support Workers on a day-to-day basis who are in turn supported by a Registered Manager from another Brandon Trust service. The absence of the Manager and the permanent Senior Support Worker has had a substantial effect on the planning and actioning of improvements and we acknowledge this within this report. During my visit it was clear that many changes have been made, including working to improve care planning, general record keeping, roles and responsibilities of staff and their working hours. However, many of these improvements are still ‘work in progress’, requiring completion. The staff I spoke with said they felt in general the many changes and improvements being implemented were positive developments for the service. However, the issues relating to ‘poor communication’ within the home at times and staff not feeling there is sufficient consistency do prevail. Whilst I could not ascertain the precise reasons for these feelings they do need to be taken seriously by the home and resolved. How the views of service users are gained and their level of input into the dayto-day running of the home remains unclear. The home’s AQAA states that their views are promoted and incorporated through ‘regular client meetings’ and that the home will ‘record the views of the clients in greater detail’. I could see no evidence to support either of these statements, as the care plan review process does not always include the views of each service user and the house meetings have become irregular, with only one being held in the last sixteen months. There appear to be no other records relating to clients views on their service or home life. The Brandon Trust have comprehensive policies and procedures to support the home, which are designed to ensure it complies with the law and remains aware of good practice guidelines. Full details of each policy were provided by the Manager as part of the AQAA he completed for us as part of this Key Inspection process. The Registered Providers’ representative makes regular auditing visits to the home and produces a short report of her findings. These reports continue to be sent to us on a monthly basis. The organisational monitoring and support remains an essential element in the development and improvements required within this service to ensure service users are provided with a safe, effective and accountable service. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 27 The Brandon Trust has a quality assurance system, which is designed to monitor and review the service provided to each person who lives in the home on an annual basis. The last review I could find was carried out in October 2006 and it is not clear if this is current. There are systems in place which are designed to support health and safety within the home and I examined a number of these during my visit. The home’s fire log shows that the alarm system is generally tested each week, although five weeks had no record of a check being carried out. The emergency lighting should be checked each month, however there are no records of checks being carried out in June and August 2007. Five staff members took part in a fire drill in March 2007, with a further two taking part in a drill in August 2007 and this is inadequate. The home does have a Fire Risk Assessment, which was last updated in July 2007. The home keeps records of hazardous products used within the home, however the Risk Assessments relating to their use have not been updated or reviewed since December 2005. All products of this nature are stored securely in the home’s laundry. The certificate relating to the safety of gas appliances expired in September 2007 and I could not find a further, up to date certificate and the home’s Employers Liability Insurance Certificate displayed in the entrance hall expired in September 2007. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 28 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 2 2 X 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 X 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 1 2 X LIFESTYLES Standard No Score 11 2 12 2 13 2 14 3 15 3 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 X X 2 2 2 3 X 2 2 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 29 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 YA1 Regulation 4 Sch.1 Requirement Each service user must be provided with up to date information regarding their service. The Statement of Purpose and Service Users Guide must be amended and then be regularly reviewed. 2. YA6 14 15 24 The registered person must write a care plan for each service users, which demonstrates how their support needs will be met. The plan must indicate each individual’s involvement in the process. The plan must be kept under review. (This requirement is repeated from the last inspection 20/01/08 report). 3. YA9 13(4) Risk Assessments must be regularly reviewed to ensure each person is supported to take risks as part of their lifestyle. DS0000008130.V348689.R01.S.doc Timescale for action 20/02/08 20/11/07 Page 30 46 Severn Avenue Version 5.2 4. YA22 22 To ensure an accountable service for each person who lives in the home all complaints made must be recorded, stored securely and be available for inspection. 20/11/07 All staff must be appropriately trained to ensure they support service users in consistent and safe way and that they can provide treatment in the event of an accident. 20/01/08 The registered person must have systems which monitor the service provided and work toward improving service provision for the service users. (This requirement is repeated from the last inspection report). 20/11/07 5. YA35 13(4) 13(5) 16(2) 6. YA38 21 24 7. YA39 24(1) The registered person must have systems in place to review the quality of service provision which includes consultation with people who use the service. (This requirement is repeated from the last inspection report). 20/11/07 8. YA42 23(4) All staff must be trained to make sure the people who live in the home receive appropriate support and guidance in the event of a fire. 20/01/08 9. YA42 23(4) All fire safety equipment must be checked regularly to ensure service users would be warned of and adequately protected in the event of a fire. 20/11/07 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 31 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. 3. 4. 5. 6. 7. Refer to Standard YA5 YA9 YA19 YA19 YA36 YA39 Good Practice Recommendations The people live in the home should have their contract of residency explained to them and sign their contracts. Each service user should be supported with risk taking to support and promote their individual development. To improve health care planning for each service user, ‘Health Action Plan’ documentation provided by the organisation should be fully implemented. To improve health care support for each service user, health screening should be implemented for people who live in the home. The frequency of staff supervisions should be improved to support them in providing a good quality service to each person who lives in the home. The frequency of service users’ meetings should be improved to ensure their views are central to the monitoring and development of the service. 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 46 Severn Avenue DS0000008130.V348689.R01.S.doc Version 5.2 Page 33 - 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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