Inspection on 04/12/07 for 535 High Lane

This inspection was carried out on 4th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

535 High Lane 07/12/06

535 High Lane 14/12/05

535 High Lane 18/05/05

535 High Lane 11/01/05

535 High Lane 01/10/04

535 High Lane 28/01/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 535 High Lane Burslem Stoke-on-trent Staffordshire ST6 7AE Lead Inspector Irene Wilkes Key Unannounced Inspection 4th December 2007 09:30 535 High Lane DS0000008214.V351041.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 535 High Lane DS0000008214.V351041.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. 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 535 High Lane Address Burslem Stoke-on-trent Staffordshire ST6 7AE 01782 862134 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) Choices Housing Association Limited Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD, 2 LD(E) Date of last inspection 7th December 2006 Brief Description of the Service: 535 High lane is a home for 8 people with a learning disability managed by Choices Housing Association. The residents may also have a physical disability and 2 people may be over the age of 65 years. The home currently has 1 vacancy. There are 3 ladies and 4 gentlemen living there. The house is divided into two separate flats, with one on the ground floor and one on the first floor. Each flat has four single bedrooms with wash basin (not en-suite), an assisted bath, lounge and dining and kitchen facilities. There is one laundry situated on the ground floor, and this has shared access with the residents living in the upstairs flat. The grounds are neat and tidy, with a parking area to the side, and lawned areas around the property for the residents to enjoy. The home overlooks the local hospital grounds to one side. There is good access at High Lane to local shops, pubs and churches and the hospital. The home is very accessible by road and public transport, being on a main bus route. Burslem is only a few minutes drive away, with all the usual facilities of a small town. The costs of the service were not available at this inspection. 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection. This means that all of the national minimum standards that the commission for social care inspection consider most greatly affect the health, safety and welfare of the residents were looked at. The inspection took place over a seven-hour period. Four of the residents were at home at different times in the day and they were spoken to individually to gain their views about living at the home. 7 resident survey forms were returned, and 2 survey forms were received from relatives. 5 staff submitted completed survey forms. The 2 deputy managers were on duty during different part of the day and each contributed to the inspection process, as did the care staff during different parts of the day. The inspection included examining a sample of 3 residents’ files and a sample of health and safety documentation including maintenance records and the records relating to fire safety. The arrangements for administering medication were looked at as well as the arrangements for safeguarding residents’ finances. The menu plan for the week was seen. The recruitment procedures were looked at as well as the training provided to the staff. This included inspection of 3 staff files. A tour of the home was undertaken. The commission requires each provider to submit an AQAA (Annual Quality Assurance Assessment). This is a legal requirement in which the home has to undertake its own review of the quality of its services and its strengths and weaknesses. Some statistical information is also required. The AQAA was returned by the manager at High Lane and was also used to inform the inspection process. What the service does well: All the residents like living at the home and like all of the staff. They really feel that it is their home in the true sense of the word. I resident lay on the settee and summed up his views well by saying: ‘This is my home. I can do this.’ Residents lead an enjoyable lifestyle with their own individual interests. The life that they lead is based on their real choices. 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 6 Relatives spoke highly of the staff at the home. ‘‘My relative is unable to speak for herself. We feel the care home takes all steps to inform us as a family to assist with getting over any important issues regarding her needs.’ ‘We have involvement with parties, meetings, and X is able to phone us with assistance.’ ‘If issues are thought to be important we are kept informed.’ ‘We are satisfied.’ ‘We feel the home has an on going training programme and always appears to be professional. ‘Our relative is fine each time we visit or phone – the home is always clean and tidy and has a very friendly atmosphere. Staff are pleasant and well informed and always ready to help.’ Residents are really empowered. They are involved in decision making in the home such as meal planning. They were aware of how to complain and said that staff helped them in this. The residents’ health care needs were being met. Residents attend routine health checks and are supported to keep any health care appointments. The staff are all very aware of each person’s needs. There is a low turnover of staff. There is enough staff on duty at each shift to meet the needs of the residents. It was very clear from speaking to the staff that they are committed and want the residents to have the best possible lifestyle. Staff are very well trained. The manager is well qualified and liked by both residents and the staff. Staff said that she has an open and approachable management style. What has improved since the last inspection? There were 4 requirements made at the last inspection and 3 of these had been addressed: There is now written consent in each residents file to give agreement to staff to administer medication to them. Recommendations made by the Fire Officer to improve fire safety in the home have been put into action. 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 7 The organisation now retains all of the information about staff that it is required to keep. This is, however, further addressed below. 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. 535 High Lane DS0000008214.V351041.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 535 High Lane DS0000008214.V351041.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): Standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who may use the service have their needs appropriately assessed before they are offered a service. EVIDENCE: There have been no new admissions to the home since the last inspection. Discussion evidenced that there have been prospective residents visits to the home but it had been considered that these residents’ needs would not be compatible with the current resident group. Residents’ views had been considered in reaching this decision, which one of them talked about to the inspector. Another prospective resident has recently visited and another visit is scheduled. The deputy manager confirmed that there would be a full record of the assessment of needs undertaken before anyone new is admitted to the home. The assessment paperwork has been seen previously and is appropriate. 535 High Lane DS0000008214.V351041.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): Standards 6, 7 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are involved in decisions about their lives, and play an active role in planning the care and support they receive. EVIDENCE: Care records continue to be person centred with full information about the support required by each individual to realise their maximum potential. A person centred planning meeting had recently been held for all but 1 resident as this had been delayed at her request. The AQAA (Annual Quality Assurance Assessment) states that these meetings had this time included more involvement from day centre and college staff, with the client’s permission. This was to promote the best possible outcome for each person through positive multi agency collaboration. 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 11 The 24 hour plan of care for each resident was particularly commendable, covering all aspects of competence, choice, influence, individuality, status, respect, continuity, relationships, community presence. The individual care plans were very informative in addressing the particular needs for support such as with mental health. There were individualised procedures in place for the management of actual or potential aggression. The organisation has plans to introduce fully interactive computer software to further develop the involvement of the residents in planning their care and expressing their aspirations for the future. Each resident has the support of 2 key workers. Discussion with the residents evidenced that they liked this approach as it gave much more regular access to a key worker on shift. The AQAA evidenced that the manager is mindful of the need to gain more insight into the needs of a particular resident and there were plans in place, including training, to address this. Records were available for all important decisions for each resident. Where restraint was used in the management of violence and aggression there were very clear records, with an audit trail, to show that this had been undertaken appropriately in the person’s best interests and consistent with the purpose of the service and the home’s duties and responsibilities. Risk assessments were in place for a range of individual areas, and the records seen showed that discussions had been held with the resident about the risks and how best to keep safe in a given situation, but to ensure that preferred activities and choices can happen. Risk assessments covered such as accessing the community alone, the management of mental ill health, undertaking various activities, and smoking, and for each there was a risk management strategy in place. One of the residents spoken with was able to confirm in a limited way that staff talked to her about her care plan and about individual risks. 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents are supported to make choices about their lifestyle, and supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: The service is good at supporting residents to develop life skills, to try to find work and take part in fulfilling activities. 1 of the residents talked about the day service that she attends on 3 days a week and the range of activities that she is involved in there, such as art and craft, music, dancing. The deputy manager confirmed that another resident is continuing with her paid job working for Choices cleaning the windows of other of their registered houses. For another resident support has been sought from the Landau trust and he has recently heard that they have found him some work experience early in the New Year. Another resident has commenced some additional college courses to extend his learning. All of the person centred planning meetings 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 13 showed discussion about the opportunities that residents wanted for themselves to further promote their learning and engagement in fulfilling work or activities. Residents are well supported to access and become a part of the community. On the evening of the inspection they were going to the theatre. Residents talked about other theatre trips, going to the pub for meals and drinks, 2 male residents go to play pool and 1 has recently requested, via his review meeting, membership of the local suburban pub, which staff are pursuing. 2 residents have season tickets for Stoke City football club. Residents also attend the ‘Rainbow Club’ a social club for people with a learning disability, and the Grocott Centre for social activities in the evening, which is another resource for those with a physical disability. Residents also talked about visiting the city centre for shopping. During the visit a resident went out alone to the shops. The staffing rotas and discussion with the deputy manager evidenced that the number of staff on duty on any particular shift is linked to the activities that are planned, with additional staff available to support these. There is good family involvement with the residents at High Lane. A number also have friends to visit and are supported to visit them in their homes. Relatives said in returned questionnaires that they are made welcome at the home and are included in parties, trips out and any events taking place. There is a very relaxed atmosphere in the home. On arrival at the house 4 people were at home and 3 had gone out to daily activities. 1 resident was in her dressing gown and said that she was just going to have her bath following her breakfast. Another resident lay on a settee. When asked by a member of staff jokingly about this he said ‘its my home, I can do this.’ Staff were observed throughout the visit knocking on doors before entering. Residents moved about the home unrestricted and staff interacted with them always in a positive way. 6 out of 7 residents said in the returned survey forms that they do what they want to throughout the day. Residents are involved in all aspects of housekeeping tasks, linked to their capabilities. The extent of this involvement is shown in individual plans and referenced in the Service User Guide. Residents at High Lane enjoy their food. Each flat develops their own menu plan for the week, and hot meal choices are made for the evening. At the visit the residents each chose their own lunch-time sandwich meal; there was no problem with each person having different fillings. The residents helped to prepare these and also to set and clear the table in the large eat in kitchen. There was evidence that a nutritionist has been involved to make sure that diets are balanced. The menu plans showed a wide variety of food choices. 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 14 535 High Lane DS0000008214.V351041.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): Standards 18, 19 and 20 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Records relating to the personal support that residents need are well documented, together with the individual choices of each person about how they want this support to be provided. The 24 hour plan of care and individualised care plans were very clear in this regard, providing well documented and thought through risk assessments that promoted independence in personal care within a risk management framework. Any new staff joining the team would know clearly what support is required from these records. Preferences for getting up/going to bed and times preferred for bathing/showering were also well recorded. The home has recognised a need for a shower, as well as a bath, in the upstairs bathroom, to facilitate choice. This has been approved by the organisation and is to be installed shortly. 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 16 Staff were observed throughout the day supporting residents in a discrete way. There is a mixed gender team of staff at the home. Each resident has 2 key workers so that there is some continuity when shifts change or at holiday times. Preferences are met as far as possible for a key worker of the same gender where this is preferred. The residents spoken with clearly had a good rapport with all of the staff team, but in particular they valued the input of their key workers. Returned residents’ survey forms were all positive about the staff. A relative in a survey form said ‘‘My relative is unable to speak for herself. We feel the care home takes all steps to inform us as a family to assist with getting over any important issues regarding her needs.’ A staff member was asked about the needs of the resident who he supports as key worker and he had a clear understanding of their needs and preferences. The AQAA states that all residents are treated as individuals and that they have an equal opportunity and diversity policy that is followed in the home. Evidence seen at the inspection supported that staff overcome barriers to ensure that individuals achieve their maximum potential. The home always responds very promptly to the changing health needs of the residents. This was noted again at this visit following the sudden change in a resident’s mental health. Supporting psychiatric services were speedily involved to mobilise the support required. This prompt response was also very evident in the past for a resident with a terminal illness, who has since died. The health needs of all of the residents are additionally well met. The AQAA states that dietetic support, vision, hearing and cholesterol checks are provided and this was evidenced at the visit. All residents have annual well women/well men health checks. The AQAA also states that there is improved liaison with the primary care team who now provide specialised support to meet clients additional health needs. Residents’ records supported this statement. There was some confusion amongst staff about the availability of Health Action Plans. Whilst health records were clearly and comprehensively available for each resident it did not appear that the residents, where appropriate, had been supported to complete and have ownership of a health action plan in line with good practice guidance. This is recommended to further promote independence and ownership of their own records that they can also take with them to any appointments. None of the service users at the home currently self medicate. At the last inspection there was no evidence to show that residents had given their 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 17 consent to staff administering medication, but full evidence was seen at this inspection that this had been addressed following the requirement being made. Medication is provided by the pharmacy in individual dosett boxes. Procedures for all aspects of the recording, handling, safekeeping, safe administration and disposal of medication were looked at by sampling and were satisfactory in each case seen. Each MAR (Medication Administration Record) that was sampled had been completed appropriately and there were no gaps in recording. Training records evidenced that care staff receive medication training. The manager is reminded that 1 newer staff member has not received external training. The manager and 2 deputies are qualified nurses. The staff on duty said that medication had been discussed at a recent staff meeting and is to continue to be on the agenda to further promote the understanding of all of the drugs used in the home and best practice procedures. It was agreed by the staff that whilst they are informally observed on shifts when the manager or a deputy manager is on duty, competency checks for medication are not routinely undertaken. It is recommended that such checks be undertaken at appropriate intervals for all staff that administer medication, and the findings recorded to give an audit trail. There are no controlled drugs currently used in the home. 535 High Lane DS0000008214.V351041.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): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure. They are protected from abuse. EVIDENCE: There is a complaints procedure on display in the home and residents also have their own copy in the residents’ handbook. The manager has recognised that this could be improved further by the development of a pictorial complaints procedure, and it is recommended that this be pursued. 2 residents who were spoken with knew about their right to complain and said that they would tell their key worker if they were unhappy with anything. ‘ My key worker sits and talks to me about things.’ They were very confident in the approach of the staff to deal with any issues for them. Returned survey forms confirmed that 6 out of 7 residents said they knew how to make a complaint, and both relatives that returned survey forms confirmed their understanding of the complaints procedure, although the AQAA identifies that residents do not have a copy and this is to be addressed. The AQAA stated, verified by staff on duty, that the complaints procedure is reviewed and discussed at residents meetings. Residents are encouraged to raise issues that they wish to be looked at. 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 19 The residents spoken with were all happy with the service provided by the home. Relatives survey forms returned were also positive. ‘Our relative is fine each time we visit or phone – the home is always clean and tidy and has a very friendly atmosphere. Staff are pleasant and well informed and always ready to help.’ A Complaints and Comments Book is kept by the home and examination of this showed that 3 complaints had been recorded since the last visit. Each was well documented and gave a clear and satisfactory recorded outcome of the investigation made into the issue. Each complaint was about issues between residents. The comments book also had 2 compliments recorded, thanking the home for the excellent care provided. The AQAA states that the home will develop a separate grumbles book. Some of the service users at High lane present with physical and/or verbal aggression and self-harm. The record of incidents and the use of restraint were examined. These showed a clear audit trail linked back to individual care plans and there was good information available to show how verbal de-escalation was tried and that restraint was used as a last resort in all instances. There has been some increase of incidents in the home, considered to be due to a death of 1 of the residents and changes in the management at the home. Staff recognised the confusion and uncertainty that this had presented for the residents and showed understanding and empathy. Some residents were being supported to have the involvement of an advocate. Training records also showed that all staff had received up to date training in the management of potential and actual violence and aggression. The home has robust procedures for responding to suspicion or evidence of abuse or neglect. A member of staff was questioned about fictitious scenarios of abuse and there was a clear understanding of constituents of abuse and reporting responsibilities. Staff training records showed that all staff had received training in this area. There have been no allegations of abuse at the home. The AQAA demonstrated an awareness by the manager of the up to date guidance regarding the wider safeguarding agenda. 535 High Lane DS0000008214.V351041.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): Standards 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well maintained and comfortable environment, which encourages independence EVIDENCE: High lane provides a safe, well maintained environment for residents with sufficient communal space to meet their needs. The house has an entrance hall and is then divided into self-contained flats, one each on the ground and first floor. There is no lift to the upstairs and so any residents with mobility needs reside downstairs. There is a comfortable lounge and large eat-in kitchen in each flat, and 4 single bedrooms, a bathroom with toilet and a separate toilet, and storage areas. Rooms are comfortable, bright, airy, clean and odour free, and provide suitable lighting, heating and ventilation. Each bedroom has a sink although none have en-suite facilities. There is a care call 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 21 in all rooms. There are handrails along corridors. The grounds are tidy and safe and accessible to the residents. The home has a planned maintenance and renewal programme for the buildings and contents. The ground floor bathroom has both a bath and a shower. There is a bath lift. A need has been recognised for a shower in the first floor bathroom where there is currently only a bath, to enable choice. Funding for this has been approved. Both bathrooms are also to be redecorated and retiled. A bedroom is to be redecorated and carpeted. The AQAA shows that in the last 12 months a new dining room table and chairs have been provided on the ground floor, three bedrooms have been recarpeted, and new flooring in toilets and new light fittings in both kitchens have been provided. There were issues at the last inspection regarding the slow response of the organisation to comply with the recommendations of the fire service regarding new regulations that came into force in October 2006. These were subsequently addressed. There is only 1 laundry on the ground floor. However, there are appropriate arrangements in place to ensure that the use of this is appropriately managed. The laundry floor is fitted with impermeable material and the walls are easily cleanable. Policies and procedures are in place and are followed to control the spread of infection, including the provision of protective clothing and suitable hand-washing provision. The home is very clean throughout. Staff are all trained in infection control. 535 High Lane DS0000008214.V351041.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): Standards 32, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support residents, in line with their terms and conditions, and to support the smooth running of the home. EVIDENCE: The staff team at High lane is experienced. The newest member of staff commenced working there some 12 months ago. The team has both male and female staff which reflects the gender composition of the residents. All staff have had MAPA (Management of Actual and Potential Aggression) training, and some staff have received additional origins of behaviour or behaviour management training. Staff have had training in understanding sexuality and inter personal relationships. Staff members were asked about the needs of some of the individual residents and they each had a good understanding of their needs and specific conditions. 73 of the care staff are trained to NVQ 2 or above. In addition to the manager, there are 2 deputy managers who are registered nurses in learning disability. There are 15 staff in total. 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 23 On arrival at the visit there were 3 staff on duty including an agency worker, due to a staff member having phoned in with illness. 20 shifts in the last 3 months have been covered by agency staff. However, there is a core team of agency staff that is generally used. There was 1 member of staff on duty downstairs with 1 resident, and 2 staff, including the agency worker upstairs, where 3 residents were at home. Staffing ratios were discussed and the rotas seen, and it was found that 3 staff are the basic staffing ratios across the day and evening, with a waking night staff from 10pm. Staff confirmed that on particular days there was more staff on duty to cover additional activities being undertaken by the residents. This was evidenced in the afternoon when 5 staff were on duty as an outing to the theatre was planned with all of the residents. All of the staff questioned said that they considered that the staffing levels are adequate to meet the needs of the residents generally, and to conduct the service safely, but felt that at times an additional staff member would allow more spontaneity for activities, particularly in the evenings and at weekends. No staff responded positively with ‘always’ to the question in the staff survey form about there being sufficient staff, but 1 said ‘usually’ there were, and 3 said ‘sometimes’. The organisation is asked to note the staff responses. Staff responded to the survey question ‘what do you think the service does well?’ with: ‘Provide staff training.’ ‘Good value base.’ ‘Activities, family contact, individual care.’ ‘Provide comfortable homes with a staff team who know their roles.’ None of the returned questionnaire from residents or relatives had staffing as an issue. Positive comments were received. ‘We feel the home has an on going training programme and staff always appear to be professional’ Whilst not an issue that the commission has authority to make a judgement on, it is brought to the attention of the organisation that in the returned survey forms 3 staff raised remuneration for unsociable hours as an area in which the organisation could do better. The recruitment procedure for their recruitment was discussed with a staff member. This evidenced that good practice was followed. Literacy and numeracy tests were undertaken, 2 references were obtained and a POVA First (Protection of Vulnerable Adults) check was completed before the person 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 24 commenced working. The full CRB (Criminal Records Bureau) check arrived later. There was evidence of appropriate supervision of the new worker. There had been a thorough induction. The staff files inspected all had relevant information to meet good recruitment practices in place, save for the worker who had been spoken with there was no evidence of a POVA First. Adequate information to confirm that this was in place in a timely way before the staff member started was ultimately provided by the organisation. However, those responsible are reminded that full recruitment information must be in place in the home for every member of staff. The commission should not have to pursue this information from the head office. Choices organisation is excellent in training staff. The staff files seen contained copies of all mandatory and specialist training, and the training records for all of the staff evidenced that all staff are up to date with all aspects of their training. A list of courses for the forthcoming year was seen, which also identified what refresher training was due for relevant staff. The AQAA states that an intensive staff induction programme that is value based and that promotes privacy, respect and dignity is provided. The induction is accredited through LDAF (Learning Disability Award Framework) and BILD (British Institute of Learning Disabilities). Choices have just received a national award for this programme. The AQAA records that existing staff are also given the opportunity to complete LDAF training if they wish as part of their personal development plan. Good practice training on sexuality, attitudes and values, positive communication and what is a learning disability is also provided. The manager is a first aid instructor, teaches sexuality and interpersonal relationships and positive communication, and has an active role on the training and development team within the organisation. The manager has identified that specific training on acquired brain injury is required by staff and is currently sourcing this training. 535 High Lane DS0000008214.V351041.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): Standards 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based upon openness and respect, has effective quality assurance systems developed by a qualified competent manager. However, the manager must make timely progress to be registered by the commission as the manager for this home. EVIDENCE: The manager at High lane is new to the home although she is an experienced manager who has transferred from another Choices home when this post became vacant in April 2007. She has not yet applied to the commission to become the registered manager for this home, but is in the process of doing so. 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 26 The manager is a registered nurse in learning disability, has her registered managers award, is a moving and handling trainer, emergency aid instructor, positive communication and sexuality trainer, LDAF assessor, and has a health and safety certificate. The manager has some devolved budgetary responsibility and manages this effectively. The AQAA provided transparent information and awareness by the manager of the home’s strengths and weaknesses and the areas for development. There was a good understanding shown of corporate priorities, an understanding of current legislation and the promotion of equality for all and the valuing of the diversity of the residents. From the information available and the assessment of the service the home appears to provide value for money. Staff on duty at the inspection were asked about their views of the manager and all said that she is very approachable and provides good leadership. The home has satisfactory quality assurance systems in place. The views of the residents are sought via individual reviews, and annual residents and relatives’ satisfaction surveys are sent out annually. The home further addresses quality by producing an annual quality report and development plan for the home. This sets out a systematic process of planning, action and review of outcomes. Attention to this was evident in the areas that have been addressed in the last 12 months and those planned for the coming year. A principal officer from Choices organisation visits the home on a monthly, unannounced basis and a report on the visit is supplied to the commission. Some maintenance and other mandatory records were looked at and these showed that maintenance of the fire system, cleaning logs, food temperature records etc. were up to date and appropriate. COSHH (Control of Substances Hazardous to Health) storage was satisfactory. Fire bell tests and fire drills were up to date. There were individual fire risk assessments available that showed attention to detail. There were safe practices operating for moving and handling of both people and objects. Servicing of the bath lift was up to date. PAT (Portable Appliance Testing) had recently been completed. There were no apparent hazards seen at the time of the visit. Evidence was seen in the care plans that individual risk assessments are reviewed on a regular basis. 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 2 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 X 3 X X 3 X 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 28 YES Are there any outstanding requirements from the last inspection? 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 YA34 Regulation 17(3) 19 and schedules 2 and 4 Requirement All of the records relating to staff working at the home must be available at all times for inspection in the care home for examination by any person authorised by the commission to enter and inspect the care home. (This was a previous requirement with a timescale of 7/1/07 and has not been completely met on every occasion) Timescale for action 04/02/08 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 YA19 Good Practice Recommendations Arrange for the residents, as appropriate, to retain their own Health Action Plan to give them greater control over ownership of their records. Undertake periodic checks on the competency of staff to administer medication. This will further help protect the DS0000008214.V351041.R01.S.doc Version 5.2 Page 29 2. YA20 535 High Lane 3. YA22 health, safety and welfare of residents. Develop the Complaints Procedure in a more user friendly format. This will further help the residents to understand about their right to raise issues that are of concern to them. 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 535 High Lane DS0000008214.V351041.R01.S.doc Version 5.2 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. 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