Inspection on 27/07/09 for 63-65 Bardsley Drive

This inspection was carried out on 27th July 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

63-65 Bardsley Drive 10/06/08

63-65 Bardsley Drive 13/06/07

63-65 Bardsley Drive 18/10/05

63-65 Bardsley Drive 19/04/05

63-65 Bardsley Drive 02/09/04

63-65 Bardsley Drive 06/04/04

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Insight - Eastchurch

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Extracts from inspection reports are licensed from CQC, this page was updated on 12/10/2009.

Key inspection report Care homes for adults (18-65 years) Name: Address: 63-65 Bardsley Drive 63-65 Bardsley Drive Farnham Surrey GU9 8UQ     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Helen Dickens     Date: 2 7 0 7 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 34 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 34 Information about the care home Name of care home: Address: 63-65 Bardsley Drive 63-65 Bardsley Drive Farnham Surrey GU9 8UQ 01252727148 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): zoe.measures@tactsouth.org Affinity Trust Name of registered manager (if applicable) Mrs Yvette Barrett Type of registration: Number of places registered: care home 3 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users to be accommodated is 3 The registered provider may provide the following category of service only: Care home only (PC) to service users of the following gender; Either whose primary care needs on admission to the home are within the following category : Learning disability (LD) Date of last inspection Brief description of the care home 63/65 Bardsley Drive has been developed from two independent semi-detached houses to an integrated establishment whereby some of the facilities are shared. It provides accommodation for 3 adults with learning disabilities. The house is located in a quiet residential area and within walking distance of Farnham town centre. The home has its own transport to support service users to access the wider community. There is off street parking at the front of the property, for two vehicles. The bedrooms are sited upstairs in both halves of the house. In addition, the ground floor area in both houses has a kitchen/diner and comfortable sitting room. The rear garden of the house is Care Homes for Adults (18-65 years) Page 4 of 34 Over 65 0 3 Brief description of the care home made up of one large patio area, with garden furniture. This is used as additional communal area, particularly in the summer months. Care Homes for Adults (18-65 years) Page 5 of 34 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This Key Inspection was unannounced and took place over 7 hours. The inspection was carried out by Helen Dickens, Regulation Inspector. The Operations Manager and the Deputy Manager represented the service. A partial tour of the premises took place, and a number of files and documents, including two residents care plans, two staff recruitment files, staff training records, quality assurance information, and the Annual Quality Assurance Assessment (AQAA), were examined as part of this inspection process. Questionnaires returned to the Commission regarding this service, were also used in writing this report. The Inspector saw and spoke with all three residents on the day of the inspection and had a more in depth discussion with one person about their care plan. Staff on duty during the day were also spoken with. Care Homes for Adults (18-65 years) Page 6 of 34 The Inspector would like to thank the residents and staff for their time, assistance and hospitality. Current fees at this home range from £1,121 to £1,750 per person per week. Care Homes for Adults (18-65 years) Page 7 of 34 What the care home does well: What has improved since the last inspection? The majority of Requirements and Recommendations made at the last inspection have been met. These include work on the environment in the home such as repairing a kitchen worktop, replacing broken plugs and a loose socket, and replacing a shed in the garden which was unsteady. Some decorative improvements have been made including the staircase walls being repainted, a toilet has been repainted and tiled, and the kitchen redecorated. Staff said residents helped to choose the new decor and helped with the redecoration. Staff training records were available for inspection and it was also noted that improvements have been made in the number of staff with, or about to receive, NVQ qualifications. Care Homes for Adults (18-65 years) Page 8 of 34 A Registered Manager has been appointed since the last inspection and she has both NVQ qualifications, and has successfully completed the Registered Managers Award. Health and safety records which were not available at the last inspection are now completed and available, and a telephone is now provided in the sleeping in room. The AQAA states, in a summary of the improvements made at the home during the year, that Policies and procedures are now up-dated, and risk assessments and guidelines have also been up-dated. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 34 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 34 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents would have the information they needed to make an informed choice about where to live, and their needs would be assessed prior to being offered a place. Each of the existing residents has a written statement of their terms and conditions with the home. Evidence: The AQAA stated that all residents have a copy of the Service User Guide, the Statement of Purpose, and contracts. It states that these are kept in their rooms, have been read to the service user, and are kept on tape in their rooms. During the inspection the Service User Guides were indeed seen in residents bedrooms, and copies of their terms and conditions, including their fees, were seen on their files. Residents had signed these documents. There have been no new admissions since the last inspection. Arrangements for new admissions would include an assessment of the prospective resident, and an opportunity for them to visit the home. Preadmission assessments on existing residents were not reviewed on this visit as they have been checked at previous Care Homes for Adults (18-65 years) Page 11 of 34 Evidence: inspections. Care Homes for Adults (18-65 years) Page 12 of 34 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents assessed and changing needs and goals are reflected in their user friendly person centred plans, and they are encouraged to make decisions and to participate in the day to day life of the home. Risk assessments are in place to minimize harm to residents, but these need to be kept under review. Evidence: Two residents files were looked at during the inspection and the inspector met with both of these people. One was spoken with several times throughout the day and he showed the inspector his person centred plan and read it out loud. He also has a taped version, and confirmed that he had agreed to and signed the various aspects. The written version was in an accessible style and format. Both residents files that were sampled contained details of the persons background, the support needed, and had a good level of detail, for example in relation to behavioural guidelines. There was information on how residents managed their activities of daily living and these were kept under review. There was information Care Homes for Adults (18-65 years) Page 13 of 34 Evidence: about peoples health needs, and each person also has a health action plan. The two files sampled identified how residents were involved in the home e.g. shopping, cleaning, and recruitment of new staff. Residents are encouraged and enabled to make decisions and were heard to be given choices throughout the day for example about their meals, what activities they wished to participate in, and how they wished to spend their time. Records of choices are made and limitations on choices are noted. Residents receive feedback about their involvement and participation for example they are involved in the recruitment process, and invited to residents meetings. They are enabled to be involved in the day to day activities of the home, for example one resident spoken with gets their own breakfast and helps prepare lunch; others help with shopping and cooking, and one has pets that they take care of, with support from staff. Relevant policies and procedures, and notices around the home, are in user friendly formats to ensure residents are included. Risk assessments are in place and residents are supported to take reasonable risks in their day to day lives. The home has general risk assessments on some topics, and then individual risk assessments as necessary, for example each resident has their own fire risk assessment. General risk assessments included for example swine flu and the hot weather, and a risk assessment for the radiators in the home which are not fitted with safety covers. Risk management strategies are in place for example how staff can support someone to avoid challenging behaviour including involving that person in drawing up the risk management strategy in the first place. One resident who was spoken with at length confirmed to the inspector that they were in agreement with the risk assessments and behavioural guidelines on their file. As mentioned earlier, a general risk assessment is in place for the radiators which covers all residents. It includes reducing the thermostatic control on each radiator, and displaying easy read signs to warn residents. The deputy manager said the subject had also been discussed with residents and they were aware of any potential danger. However, one resident has recently been diagnosed with a health condition which may make them more at risk than the other residents. A more personalised risk assessment needed to be drawn up for this resident. The Operations Manager said she would ensure this was in place within 24 hours. The registered manager later confirmed by telephone that this had been completed. She also said that various items of furniture had now been moved so that residents were less likely to come into Care Homes for Adults (18-65 years) Page 14 of 34 Evidence: contact with radiators, until the issue could be resolved. The absence of radiator covers was highlighted at the last inspection as an area needing attention. The Operations Manager said quotations had been obtained but the radiators were not regular sizes and therefore it would be expensive to have individual covers made for them all. She was looking at the possibility of arranging for those which potentially posed the most risk to be done first. In the meantime the relevant risk assessments must be reviewed regularly, and action taken as necessary to prevent harm to residents. Care Homes for Adults (18-65 years) Page 15 of 34 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users can take part in interesting and fulfilling activities, and are encouraged to be part of the local community. Family and friendship links are encouraged, and daily routines are flexible to suit residents needs. Meals and mealtimes are flexible and arranged to suit residents preferences, though specialist advice should be sought to ensure they are receiving a nutritious and well balanced diet. Evidence: Residents take part in interesting and fulfilling activities at this home. This includes domestic activities, further education, and leisure pursuits. Domestic activities include cooking and helping to keep the home clean. Photographs were seen both displayed in the home, and in person centred plans, of residents being supported to cook meals and bake cakes. Leisure activities include horse riding, bowling and using local pubs and restaurants. One resident is musically talented and plays a number of instruments including an electric keyboard. All residents meet fortnightly in one side of the houses Care Homes for Adults (18-65 years) Page 16 of 34 Evidence: for a music session. All three residents returned a survey to the Commission, with help from staff, and ticked that they could Always make decisions about what they did each day. Residents are involved in working on the front and rear garden/patio areas, both of which are tidy and colourful with well kept patio pots and borders. There are some vegetables in a grow bag in the back garden, and one resident has their own outdoor pets. Residents attend various further education day services and take part in activities such as horticultural therapy, hockey, and various arts and crafts. One resident has a music teacher who gives him lessons at home. The Operations Manager said residents had also participated in equal opportunities training some years ago. Staff ensure residents are supported to use local facilities for example specialist day services for leisure and education, and local services such as health facilities, shops, and the library. Activities plans and daily notes show time and staff support is allocated to residents to use community activities such as going to the pub and to the bank. Residents take part in the local recycling scheme and were seen to take out bottles etc to their collection box in the back garden. The service works to maintain a neighbourly relationship in their local community by ensuring any issues with neighbours are addressed, and the homes front entrance and drive are attractively maintained and in keeping with other properties. Residents are encouraged to pursue their own interests and hobbies, and the deputy manager said residents also have two holidays a year as a group, plus other individual holidays or outings. She encouraged one resident to talk about one of the group holidays where they go and stay in a castle, and where they each have their own room. There were some photographs of this holiday displayed on the wall with residents dressed in medieval costumes and obviously enjoying themselves. Residents are supported to have relationships, and it was noted that two residents socialise together outside the home. Staff were found to be knowledgeable on the family and friendship links of each resident, and contact with family and friends is encouraged. Residents files begin with a section on important people and family connections for each resident. Guidance is given about visitors and one resident showed the inspector a copy of this on his person centred plan. Bedrooms are personalised with photos of family and friends. Residents can choose whether to be alone or in company. One who prefers their own company has arrangements in place for this, for example they have their own separate rooms in one side of the house, Care Homes for Adults (18-65 years) Page 17 of 34 Evidence: including their own kitchen, bathroom, bedroom and lounge. Strategies and risk assessments are in place around relationships as needed. Routines at this home promote the independence of residents. There were many examples including one person who gets their own breakfast, and starts making their own lunch when they are ready to eat. To enable one resident to be comfortable about who will be assisting them, a daily staff rota is displayed on the kitchen notice board. Activities plans are in place but staff said these are flexible to suit residents needs on the day. There were several examples of staff diverting from what they were doing to assist a resident, and staff were seen to interact well with service users and included them in conversations and decision making. The deputy manager and operations manager confirmed that residents open their own post but may then give it to staff to read. Staff knocked on doors before entering and waited for residents permission before going in. All residents have their own bedrooms. The Recommendation at the previous inspection to review the arrangements for locks on residents bedroom doors had not been carried out. One type of key, a star key, opened several doors including residents bedrooms. The registered manager confirmed by telephone that since the inspection she had arranged for all bedrooms to be fitted with individual door locks and residents now had their own keys. Meals and mealtimes are flexible to suit residents preferences, and they are encouraged to be involved in all aspects of their meals including shopping and cooking. One resident spoken with gets their own breakfast, and starts off their lunch preparation, asking for staff support as needed. Some residents have cooking sessions with staff, and there are risk assessments on file for kitchen activities. Residents can eat alone or in company, and arrangements were seen to be in place to meet residents preferences in this regard. Records are kept of the actual meals eaten and health action plans contain details of special needs in relation to meals. One resident needs to have observations made about their mealtimes and their fluid intake measured, and records of this were seen. Residents weights are also recorded. Staff said residents assisted with shopping and chose what they would like to eat. For two residents staff said there was no menu plan for the week; only a record of what has already been eaten. Staff said residents are asked during each day what they would like to eat. Whilst this encourages independence and choice, it would make it more difficult to manage a well balanced diet. One resident was overhead to be given four choices for supper and said no to each option. The choice is limited to what is Care Homes for Adults (18-65 years) Page 18 of 34 Evidence: available in the fridge, freezer and cupboard (which would of course have to have been purchased in advance) and, giving a completely free choice might entail too many unhealthy choices. One of the choices given was sausages, yet this residents record of what they had eaten showed that they had sausages or a fry up most mornings for breakfast. Another resident was said to not like fruit and has tinned food for lunch each day. This person did have a menu plan and staff said five of the seven evening meals that week included homemade food. This would have included several vegetables, but it would not have been possible for the person to get the recommended five portions of fresh fruit and vegetables per day. One evening meal was fish and chips and contained no vegetables at all, as potatoes do not count. The operations manager said she would guide staff to look at other ways of ensuring residents had a nutritious diet, for example the introduction of fruit smoothies. However, it is also recommended that a dietitians advice be sought. In a call to the inspector following this visit, the registered manager said she would be seeking a dietitians advice as recommended, but had also given interim guidance to staff on this matter. Care Homes for Adults (18-65 years) Page 19 of 34 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive personal care and support in a way they prefer and require, and their health needs are identified in their health action plans. Arrangements are in place which should ensure the safe administration of medication. Evidence: Two person centred plans (PCPs)were sampled during the inspection, one of these being read to the inspector by the person themselves. Both PCPs sampled were in user friendly formats, and contained each residents preferences about their personal support, though people who live at this home are fairly independent in this respect. Where certain aspects of personal care support is needed, this was noted and guidelines were in place. Staff were observed to support residents in a sensitive and patient manner, and personal care was carried out in private. Specialist nursing care is provided by a community Psychiatric Nurse to one resident who was spoken with. Residents keep a copy of their PCPs in their rooms and where possible had signed their agreement to the plan. All three surveys returned from service users showed that they had ticked that carers Always listened to them, and acted on what they said. Care Homes for Adults (18-65 years) Page 20 of 34 Evidence: Residents have their health needs and goals identified in their own health action plans; these are set out in a user friendly format and summarise each persons general health. There is a list of activities that will maintain and improve peoples health, including some physical activities. Records of health check ups are noted for example with the dentist, chiropodist and optician. Records of specialist appointments and assessments showed input from, for example, the Speech and Language Therapist and the psychiatrist. Each resident has their weight recorded, and any special monitoring is noted. There is a record of immunisations for each person, and the medication they are taking. Each plan also has a general health assessment for the person to take with them if they are admitted to hospital. Observations on residents diet and nutrition are noted earlier in this report and a Recommendation had been made on this subject. Medication arrangements encourage residents to be as independent as possible and one administration session was witnessed and demonstrated how residents can be more involved in medication arrangements. The medication is kept securely and the records sampled for one resident showed there were no unexplained gaps. Staff said the next person on shift checks records to ensure no medication has been missed. Guidelines are in place for staff on the safe administration of medication, and a list of specimen staff signatures is kept on the front of the administration records. A risk assessment for the self administration of medication for one client was seen and recently reviewed. There was no record of the last pharmacy inspection by the local pharmacist, though the operations manager said she remembers such inspections taking place in the past. She said these visits used to be done by a local pharmacy but not for some time. A Recommendation will be made to follow this up. Care Homes for Adults (18-65 years) Page 21 of 34 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users complaints would be taken seriously at this home, and there are procedures and staff training arrangements in place which should protect them from abuse. Evidence: In relation to complaints, the AQAA returned to the Commission stated that We try and deal with matters before they escalate. Residents are given copy of complaints procedure and these were seen during the inspection. The AQAA stated one complaint has been received since previous inspection. This was sent to the local authority and copied to the Commission and has now been dealt with. There have been no other complaints since the last inspection. Staff were observed to listen to clients and act on their views and concerns, and residents were seen to go to them for advice and guidance. Three service user surveys were completed with assistance from staff, and returned to the Commission; these showed residents knew who to speak with if they were not happy, and how to make a complaint. The AQAA states that there is a Whistleblowing Policy in place and that this was last reviewed in August 2008. The home has the local Surrey Safeguarding Adults Policy and in-house policy which gives guidance to staff about what to do if there is a safeguarding vulnerable adults issue at the home. The operations manager said staff have initial training on this during their induction, and then annual refresher training. Staff training records showed that all but one staff member was trained in safeguarding adults in the last Care Homes for Adults (18-65 years) Page 22 of 34 Evidence: year. One last had training in 2007 and was due for a refresher. A complaint raised and forwarded to the local authority (noted in the last inspection report) was dealt with under the local authoritys safeguarding procedures and they confirmed that this has now been satisfactorily concluded. Care Homes for Adults (18-65 years) Page 23 of 34 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live at Bardsley Drive benefit by being in a homely and comfortable environment, which is personalised to suit their needs. The home is generally clean and hygienic though hand washing arrangements will need to be reviewed. Evidence: The AQAA returned to the Commission states that All the service users are proud of their home. It did not confirm whether the previous Requirements relating to the environment had been met. A partial tour of the premises took place and both sides of the home were visited. One side of the premises had a very homely lounge, with comfortable domestic furnishings and fittings. Art work, and certificates of achievement were displayed, as well as photographs of residents. One of the residents who uses this lounge was pleased to tell the inspector about the activities and events portrayed. The other lounge was also very personalised but needed freshening up, and the carpet was stained and very faded in places and needed to be replaced. Two bedrooms were visited and found to be very personlised and both residents said they had everything they needed. Both sides of the home have their own kitchens and these too were personalised to suit the residents who live there. One resident likes to know about the weather and Care Homes for Adults (18-65 years) Page 24 of 34 Evidence: staff put the daily weather forecast on this persons kitchen notice board. This person also had their own personal menu, and a microwave where they make their own porridge for breakfast. The other kitchen was equally personalised with activities boards and a star chart which one resident completes, and is linked to their progress with independent living skills. All but one of the issues highlighted at the last inspection regarding the premises appears to have been met. The concerns regarding the absence of radiator covers are discussed earlier in this report, and later under the management section. Notices, in user friendly language and pictures, were seen throughout the home near radiators, to warn residents of the potential dangers. As noted earlier, the premises and outdoor areas are in keeping with the local community and have a style and ambiance that reflects the homes purpose. The front and rear patio and garden areas are well kept and there was plenty of evidence of residents being involved in this. The AQAA returned by the service does not contain any information about the hygiene arrangements at the home. During the inspection it was noted that the home was generally clean and tidy, with no unpleasant odours. As noted at the previous inspection, laundry facilities are in each kitchen on the ground floor. However, it was noted that there was no hand washing liquid in one of the upstairs bathrooms, and an upstairs toilet has no hand basin and staff have to go next door to the locked staff room to wash their hands. One kitchen also had no hand washing liquid. These concerns were discussed with the operations manager at the time who said she would ensure that suitable hand washing arrangements would be made. A Requirement is being made to review hand hygiene arrangements. This should be linked with the homes infection control plan which the AQAA stated was in place, but could not be found on the day of the inspection. Care Homes for Adults (18-65 years) Page 25 of 34 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported by competent staff and the home is working towards having more staff with qualifications in care work. Recruitment arrangements need further work to fully protect residents. Training arrangements have improved and should ensure that service users needs are met by appropriately trained staff. Evidence: The AQAA returned by the service states that they provide A continuity of care to residents. It does not state whether the Requirements made on staffing at the last inspection have been met. Staff were observed to be approachable and service users came to them for support. The staff were seen to follow guidelines and know residents support needs well. For example one person likes to have staff involved in taping their daily diary, and all staff, including the operations manager, were seen to be supportive and get involved as requested. The AQAA states that instances of challenging behaviour have decreased, and the inspector noted that staff were aware of, and dealt well with, balancing the needs of individual residents during the day. Residents who needed one to one support or supervision were assisted in a timely way. From the details on the AQAA, and speaking with operations manager during the Care Homes for Adults (18-65 years) Page 26 of 34 Evidence: inspection, the home is also making improvements in the number of staff with qualifications in care work. So far three of the ten staff have NVQs already; three have recently completed their NVQs and are awaiting their certificates. Four others have now started NVQs at either Level 2 or Level 3. Two staff files were checked during the inspection. Both contained application forms, two references, photographic identification, evidence of an induction being completed, and Criminal Records Bureau and POVA checks, to ensure these staff had not been deemed unsuitable to work with vulnerable adults. One file showed a short gap in employment history, but the other had a gap of over 20 years. The references for this person may not have been appropriate and the manager would have needed to see a full employment history before deciding which referees would be the most appropriate. This means a Requirement from the last inspection has not been met and the Commission will now consider whether enforcement action is needed in this regard. Since the inspection, the registered manager has confirmed that a full employment history has been sought and documented for both members of staff. Training arrangements were discussed with the operations manager during the inspection. She confirmed that training details were available and therefore the Requirement made at the last inspection has been met. She stated that there is a training programme in place, and certain essential training is done by all staff. For example, from the training records sampled it could be seen that all staff did moving and handling training in either 2008 or 2009; all had done health and safety training; and all had done safeguarding adults training, though one was due for a refresher. The operations manager said there is always at least one staff on duty who has done first aid. Records also showed that all but one staff member did food handling training in either 2008 or 2009. The two staff files sampled showed that staff had done induction training, and the organisation now uses the Skills for Care recommended induction process. The AQAA stated that extra specialist training has been undertaken, and the operations manager said staff and residents have received training in diversity and equal opportunities. Care Homes for Adults (18-65 years) Page 27 of 34 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from living in a home with a registered manager in place, and where improvements continue to be made. Their views are taken into account in running and developing the home, but more work needs to be done on quality assurance processes and health and safety arrangements. Evidence: This home has appointed a new manager since the last inspection, and she is now registered with the Commission. The previous Requirement on management has therefore now been met. The new manager was not on duty during this inspection but the deputy manager and operations manager were able to assist. The new manager has recently registered with the Commission and therefore has been deemed competent and sufficiently experienced to run the home. In the last 12 months she has completed the Registered Managers Award, and already has an NVQ4 in care. One of the staff surveys returned to the Commission noted that Its a really good place to work. Good team of staff and the manager. Care Homes for Adults (18-65 years) Page 28 of 34 Evidence: A number of issues were highlighted to the operations manager in relation to the overall management of the home. The AQAA was very brief and contained little information about the service; neither did it clarify which if any of the previous Requirements and Recommendations had been met. The operations manager said she though it would be useful to arrange some in house training for all home managers on how best to complete the AQAAs. During the course of the inspection it became clear that not all the Requirements and Recommendations from the previous inspection had been met, and this needs to be addressed. It is recognised that a number of improvements have been made since the last inspection and these are noted elsewhere in this report. There are a number of quality assurance processes in place at this home including Regulation 26 visits on behalf of the provider, and a quality assurance policy and programme of monitoring the activities of the home. The Regulation 26 visits gives the home a score on the various outcome areas, and this includes looking at activities, speaking with staff and residents, checking service users financial records, and ensuring safety checks have been carried out such as fire alarm checks. The operations manager said that their own quality assurance format (Key Outcome Audit Tool) looks at all the relevant areas including residents assessments and support plans and the environment. She said there is an action plan with the Tool, which helps services to address any shortfalls. Residents meetings are held 4-6 weekly and individual residents support plans demonstrate the goals they working towards. Service users opinions were heard to be sought throughout the day of the inspection. However, despite a detailed quality assurance system, the service is not identifying some important shortfalls, for example unmet Requirements and Recommendations from the previous inspection, and this needs to be reviewed to ensure the service is monitoring itself, and that any shortfalls are identified and dealt with in a timely manner. There are arrangements in place to promote the safety and well being of service users. For example staff have done relevant training, such as moving and handling and health and safety. It was also noted that PAT electrical testing has been completed in June 2009 on all the kitchen appliances. Fire safety arrangements are in place e.g. checking emergency lighting and fire alarms, and fire evacuation practices with the last one being in June 09. Regulation 26 visits on behalf of the provider check these arrangements are being followed, and reviews any Regulation 37 notifications (these are reports about any significant events affecting the welfare of residents), and accident and incident records are checked. Water temperatures are monitored, and Care Homes for Adults (18-65 years) Page 29 of 34 Evidence: there are notices up in the home, in a user friendly format, warning of potential dangers such as that from radiators. The last Environmental Health Officers visit in 2006 recorded that there were no problems found at the home. However, since the issue was highlighted at the last inspection there appears to have been little progress on getting radiators covered except for quotes being sought. Some measures are in place including user friendly notices, and thermostats being turned down on each radiator, but during the last 12 months one residents needs have changed and as stated earlier, there now needs to be a specific risk assessment carried out to ensure all the necessary action is taken to minimise the risk to this resident. The operations manager said she would ensure this was completed within 24 hours. Staff said water temperatures were monitored and recorded but the record book showed large gaps in recording. For example from 1st July until the date of the inspection nearly 4 weeks later, none had been recorded. Prior to this, some temperatures were recorded as too hot but it was not clear what action had been taken. Staff told the inspector that the main tank temperature gets turned down to prevent scalding. The thermostat on the main tank was seen and did appear to be set to a low temperature and may have prevented scalding, but could have left the home open to a higher risk of legionella. The operations manager agreed to contact environmental health for advice on this issue straight away and then to review their arrangements for the prevention of legionella. The home should ensure that their systems comply with the Health and Safety Executive guidance booklet on the prevention of legionella in care homes. Following this inspection the registered manager confirmed that environmental health advice was sought from the local council and they had visited the service. She said that they had now received a certificate from the officer who carried out the inspection to show that the arrangements were now satisfactory. She said that she had also had all the thermostatic valves on the taps replaced since the inspection, to ensure that water temperatures at each basin were controlled to within safe limits and to prevent scalding. Care Homes for Adults (18-65 years) Page 30 of 34 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 34 19 All staff must have appropriate checks undertaken before commencing work in the home. 11/06/2008 Care Homes for Adults (18-65 years) Page 31 of 34 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 All the relevant risk assessments must be in place, and be kept under review, to reflect the changing needs of service users. For the safety and welfare of service users. 03/08/2009 2 24 16 Arrangements for hand 03/08/2009 hygiene must be reviewed and the means to wash and dry hands must be available in all the appropriate places. To minimise the risk of infection. 3 34 19 All staff recruitment files 27/08/2009 must contain the relevant information as set out in Schedule 2 of the Care Homes Regulations 2001 (as amended). For the safety and welfare of service users. Care Homes for Adults (18-65 years) Page 32 of 34 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 4 39 24 The arrangements for 27/08/2009 monitoring the quality of the service must be reviewed to ensure any shortfalls are identified and dealt with in a timely manner. For the welfare of service users. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 17 20 The advice of a dietitian should be sought to ensure residents are receiving a nutritious and well balanced diet. The home should follow up with the designated pharmacy or health agency about when their next pharmacy inspection is due, and records of these visits should be kept at the home. The carpet in one lounge is stained and faded, and should be replaced. 3 24 Care Homes for Adults (18-65 years) Page 33 of 34 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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