Inspection on 07/09/07 for 68 High Street

This inspection was carried out on 7th September 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

68 High Street 12/08/08

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 68 High Street 68 High Street Loscoe Nr Heanor Derbyshire DE75 7LF Lead Inspector Tony Barker Key Unannounced Inspection 7th September 2007 09:30 68 High Street DS0000069782.V341948.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 68 High Street DS0000069782.V341948.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. 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 68 High Street Address 68 High Street Loscoe Nr Heanor Derbyshire DE75 7LF 01773 533075 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) M & A Dispensing Chemist Ltd Janet Wain Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following category of service only: Care Home only - Code 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 - Code LD The maximum number of service users who can be accommodated is 3 This is the first inspection since a change of registered provider in April 2007. 2. Date of last inspection Brief Description of the Service: 68 High Street, Loscoe, is a small care home registered for up to 3 people with a learning disability. The Home is a terraced house, situated in a residential area, on a main road. Each service user has their own single bedroom. The Home has not been adapted for people with physical difficulties and it has steep stairs leading to the bedrooms and bathroom. The Home has a small staff team operating on a rota basis, providing one member of staff on duty at all times when service users are at the Home. The current service user group all have a moderate to mild learning disability so that the Homes service are geared up to high levels of independent activity. There is parking space for one car. 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 8 hours and was a key unannounced inspection. Two service users, the Deputy Manager, one care assistant and a Support Manager from the Company were spoken to, records were inspected and there was a tour of the premises. Two service users were case tracked so as to determine the quality of service from their perspective – the third service user was spending a short holiday with their relative. Survey forms were posted to all three service users and to their relatives. Short notice was given for return of these and only one relatives survey form had been returned by the start of this inspection. The information from this form was analysed before the inspection and the outcomes included in the inspection process and reflected in this report. This inspection focussed on all the key standards. The pre-inspection, Annual Quality Assurance Assessment (AQAA), questionnaire was reviewed prior to this inspection. The Home’s fees were stated on the Service Users’ Guide as being £358.65 per week. What the service does well: What has improved since the last inspection? What they could do better: When medicine is provided to service users, for their use, it must be from the correctly labelled container that the pharmacist has provided. Staff must not be employed unless required information and documents, relating to their recruitment, are in place. All staff who handle food must be provided with Basic Food Hygiene training. The Manager must attain an appropriate qualification in ‘Care’ at NVQ level 4 and commencement of a management qualification at NVQ level 4. She must spend enough time at the Home to ensure that it is managed with sufficient care, competence and skill. Monthly 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 6 independent audit visits to the Home must take place. Gas appliances must be serviced annually, and electrical wiring checked every five years. 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. 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual written needs assessments were in place before people were admitted to the Home so that their diverse needs were identified and planned for. EVIDENCE: The Home’s Statement of Purpose was generally satisfactory but it did not contain all the items listed in Schedule 1 of the Regulations. For example staff qualifications and experience were not recorded. Service users had each been provided with a copy of the Service Users Guide. This was satisfactory in its content although it was not in a format suitable for the individual service users. The Registered Provider had indicated to the Commission, in a letter dated 16 April 2007, that the supply of a suitably formatted Guide would be given priority. All the service users had been admitted to the Home through the Social Services’ care management system. Individual care plans were in place based on an initial assessment of each service user’s needs. The Home had a written policy/procedure on introductory visits for a prospective service user, prior to admission, but this did not mention the requirement for a full needs assessment at that point. 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users had individual and up to date plans of care which demonstrated that their health, personal and social care need were being met. A ‘person centred’ approach was being taken to ensure that service users’ individual needs and wishes were focussed on. EVIDENCE: All service users’ file were examined – two of these being part of the case tracking process. The care plans were being updated and reviewed on a regular basis. They had a satisfactory mix of personal needs and goals. Once a year, a care plan review meeting was held for each service user, with the service user, care staff, relatives and external professionals invited. As part of the review process the Deputy Manager stated she approaches the local authority day services and voluntary work settings, attended by the service users, for feedback at review meetings. Six monthly in-house reviews of care plans were also taking place. The care plans confirmed the considerable degree to which the Home was enabling service users to achieve their aspirations. There was good evidence that a ‘person-centred planning’ (PCP) 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 10 approach was being followed. However, this was not reflected in the Home’s documentation which also contained no examples of pictures or symbols appropriate to the service users’ degree of understanding. The Home’s Day Book was examined and was found to contain a range of informative comments that usefully inform the care planning process. Information ‘Front sheets’, ‘likes and dislikes’ lists and Personal Log Sheets were in place. There was plenty of evidence of each service user taking a lead in formulating their lifestyles and involvement in the day-to-day running of the Home and decision making. This came from discussion with service users and staff and from ‘Residents Feedback’ sheets. However, there had recently been examples of some lessening of this involvement - including lack of consultation in changes to the system of self-medication and in the planning of internal decoration of the Home – although service users had been consulted over colour schemes. The care assistant spoken to provided several examples showing how service users make decisions and choices and exhibit relatively high degrees of independence in certain situations, including the use of public transport and in personal finance. It was clear from talking to this staff member how motivating it was for her to note the individual achievements of service users. The Home’s Policies and Procedures file included eleven recorded risk assessments covering a wide range of potential hazards. These were mostly environmental, and of relevance to all the service users, though some were solely related to individuals. The care assistant spoken to gave examples of service users taking ‘responsible risks’ in order to personally develop. She spoke of one service user who goes off on their own for an hour when the group of service users go out with a member of staff. Being able to tell the time from a watch, this service user was usually back at the agreed meeting place before the agreed time, she said. 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home provided activities and services that were age-appropriate and valued by service users and promoted their independence. EVIDENCE: The care assistant spoken to gave examples of service users being involved in valued and fulfilling activities. One case tracked service user confirmed a particular love of shopping and another spoke enthusiastically about using the internet on a college computer. This service user also spoke with pride at working on two weekdays at a local golf club, saying, ”I do a lot of different jobs there”. All three service users attended structured daytime activities each weekday, including day centres, college and working as volunteers in a range of capacities. One service user attended two self advocacy groups – representing other people with learning disabilities. This service user was in receipt of payment for one of these roles. It was clear that the service users were involved in activities that they personally valued and the degree to which these were fulfilling and individually tailored was commendable. There was 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 12 evidence of service users views being listened to regarding this summer’s holiday arrangements – when they all went to Scarborough with two staff and experienced a more enjoyable pace of holiday than usual. Care records indicated how staff supported service users to be involved with the local community. The care assistant spoken to said that they were well known by local shopkeepers and those in neighbouring towns where staff accompany two service users to on alternate weekends. The Home encouraged independent use of public transport and two service users frequently used it. Regular use was made of a local gym, cinema, shops and pubs. Each of the service users was spending alternate weekends with their parents – an experience that they each found enjoyable. The care assistant spoken to said that if a service user wanted to stay back at the Home, rather than visit their parents, then staff would be allocated to cover additional shifts. There was a photograph in the kitchen of one service user with parents. A service user spoke warmly of the other two being their friend and both said they had a good friend at day service/college, although they did not see them outside that service. Service users’ individual responsibilities for housekeeping tasks were recorded and displayed on the inside of kitchen cabinet doors. The care assistant spoken to said there were many routines in the Home that promoted service users’ independence. These included housework, shopping, ordering food at a restaurant and using cash cards. She added that staff and service users undertake household jobs together and that routines were flexible and reflected individual needs and wishes. Food stocks in the kitchen were at a good level. There was evidence of service users’ individual tastes being catered for – with food bought by themselves placed on labelled shelves in the kitchen wall cupboards. Both service users spoken to were positive about the food they ate and all were involved in its purchase and preparation. The Home’s four-week rolling menu showed a varied range of nutritious meals provided and indicated that Thursday night is when a meal out is eaten. The Deputy Manager said that the menu is not adhered to rigidly. 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The use of unlabelled medicine bottles means that service users may be given the wrong medicine. This puts service users at risk of harm. EVIDENCE: The Home had flexible routines based on service users’ assessed needs, stated preferences and activities being undertaken. Discussion with the Deputy Manager and one care assistant showed that the staff had good knowledge of the service users’ individual preferences and interests. Both service users spoken to confirmed that staff listen to them and act on what they say. The care assistant spoken to gave examples of how the Home was meeting service users’ privacy needs. There was evidence of staff and service users knocking on doors before entering a bedroom and on the door to the front lounge when one service user is watching television there. There was a privacy lock on the bathroom door and there was a written risk assessment to address privacy needs of service users whilst they are bathing. The care assistant spoke of one service user who, with staff support, had gained sufficient confidence to use the bath. 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 14 All the service users were receiving regular chiropody, dental and optician appointments. They also regularly attended local clinics for personal health needs such as diabetes and asthma. A dietician was currently involved with one service user and the Deputy Manager described sound and sensitive practice in relation to this service user’s diet. Medical appointments and outcomes were well recorded. Very comprehensive records of health appointments had been made on each service user’s Personal Log Sheets. The Inspector spoke to the care assistant about the benefits of taking a ‘person centred approach’ to the recording and action taken with respect to service users’ health needs – through Health Action Plans. Medicines were being kept securely in a locked wall cabinet in the laundry/utility room. Only two of the service users had medicines prescribed for them and they self-medicated with support from staff. Signed declarations of self-administration were seen. Following re-registration of this Home in April 2007 medication blister packs and printed Medication Administration Record (MAR) sheets had been introduced in order to improve safety. Service users had objected to the blister packs, as it introduced more dependency on staff, and the Home returned to the use of pharmacy labelled bottles. Staff were still coming to terms with the new MAR recording system and felt they had not received enough support in its use. Recording practices were satisfactory except that there was one handwritten MAR sheet without countersignatures. Running daily totals of tablet numbers were being recorded as an additional safeguard now that blister packs were no longer in use. Service users’ photographs were in place beside individual MAR sheets. There was no record of specimen staff signatures/initials. The Inspector was shown an empty bottle of Metformin oral solution, used by one service user between 23 July and 19 August 2007, that had had its pharmacy label ripped off, leaving doubt as to whether this was the actual solution prescribed for this service user. This was concerning. Some medication was being occasionally administered ‘prn’ (as and when required) – for example, an inhaler and paracetamol tablets. There was no general written policy on the administration of ‘prn’ medication. Staff had recently received training in the safe use of medicines through an in-house training video. 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good practices were being followed regarding the handling of complaints and the protection of service users from abuse, so ensuring that they were safe. EVIDENCE: The content of the Home’s complaints procedure was satisfactory and was clearly displayed in the kitchen. It did not contain any symbols or pictures appropriate to the service users’ degree of understanding. The two service users spoken to were clear as to whom they would speak if they had a problem. The relative who responded to the Commission’s postal survey confirmed they knew how to make a complaint about the quality of care provided by the Home if they needed to. The Manager stated in the AQAA that there had been no formal complaints in the last 12 months and the Home’s Complaints Record confirmed this. The care assistant spoken to described a clear system of addressing and recording service users’ concerns, that fully involved them. The Home had a ‘Adult Protection Procedures and Prevention of Abuse’ written policy as well as copies of the statutory Safeguarding Adults Procedure. The Home’s policy stated that service users had a right to withhold consent to a referral being made to the Social Services Department following suspicion of abuse. It was pointed out to the Deputy Manager that this was not acceptable practice as Social Services are the lead agency regarding ‘Safeguarding Adults’ incidents. The written policy also stated that if there was an allegation of a member of staff abusing a service user, that person would not be suspended until an internal investigation had been undertaken. Again, it was pointed out 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 16 to the Deputy Manager that this was not safe practice. However, the Deputy Manager said she was aware of the inappropriate wording of the policy. There was a separate policy on Whistle Blowing and this made appropriate reference to staff, who whistle blew, not being victimised. The care assistant who was spoken to showed a good understanding of this policy. All staff had attended the Social Services briefing on the statutory procedures. The Support Manager, present at this inspection, stated that the Manager had attended a Safeguarding Adults training course run by Age Concern. The two service users confirmed that staff treat them well and they felt safe living at the Home. Records of use of service users’ cash cards and personal monies had both staff and service users’ signatures. These were examined and crosschecked against monies held in respect of one service user. The cash amount was found to be correct. 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were living in a safe, comfortable and homely environment. EVIDENCE: One of the service users showed the Inspector around the House. This tour of the premises indicated that material standards were reasonably good and the Home was comfortable and homely. The Home was being decorated at the time of this inspection and the Manager, in the AQAA, described the range of replacement furnishings planned. To the rear there was a conservatory, patio and small garden. The care assistant spoken to described how the service user were involved in gardening. Two of the service users personally showed the Inspector their bedrooms. The rooms were very well personalised and clearly indicated the range of interests held by them. The laundry facilities were satisfactory and the Home was found to be clean and hygienic, with no unpleasant odours. The two service users said that the Home was always fresh and clean. The Manager stated in the AQAA that Infection Control training for staff was planned. 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home’s recruitment practices and staff training fell short of fully safeguarding the welfare of service users. EVIDENCE: The Manager stated, in the AQAA, that 50 of the staff group of four care assistants had achieved a National Vocational Qualification (NVQ) at level 2 in Care and NVQ training for one further staff member had been arranged. This met the National Minimum Standard to maintain a staff group with at least 50 qualified staff. The staffing rota was examined and it was noted that it did not include the Manager’s name. When asked about this the Deputy Manager said that the Manager had spent very little time in the Home since its re-registration in April 2007. In other respects, staffing levels were satisfactory. One case tracked service user spoke of missing the previous male Manager. With regard to this issue the Support Manager spoke of plans for a male member of staff to join the staff group in order to provide an improved gender mix. 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 19 The file of a member of staff appointed in May 2007 was examined. The information and documents relating to her recruitment did not fully meet the Regulation requirements. There was no... • proof of identity, including a recent photograph, • written verification of the reason why she ceased to work in a previous role with vulnerable adults or • written explanation of two gaps in her previous employment record. Additionally, both written references were of a ‘To whom it may concern’ type, with no verification of their authenticity. It was noted that there was a generally stable staff group. The recently appointed member of staff had received in-house induction training to a reasonable standard. However, it was not to the Skills for Care Common Induction Standards. Training records confirmed that all staff had been provided with all mandatory training except in Basic Food Hygiene. The new member of staff was booked on a course of Moving & Handling training in October 2007, the Deputy Manager said. Additional specialist training sessions had been provided for staff on Prader-Willi Syndrome, Diet and Nutrition, Asthma and on Diabetes. One of the service users had epilepsy but staff had not been provided with specialist training on this topic, for instance from an Epilepsy Nurse. The Support Manager spoke of the Manager planning to soon take over responsibility for the supervision of staff, from the Deputy Manager, in order to improve her knowledge of staff and service users. Other aspects of Standard 36 were not assessed on this occasion. 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management practices were not satisfactory and service users’ health and safety could be compromised. EVIDENCE: The Manager had worked in the care profession for seven years, mainly as a care assistant working with older people. She had eight months experience as Deputy Manager at a care home for older people owned by the Company to which this Home is now registered. She has acknowledged to the Commission that she has limited experience in caring for younger adults with learning disabilities. The Support Manager stated that plans were in place for the Manager to be provided with training to increase her knowledge and skills in caring for people with a learning disability. The Manager had yet to attain an NVQ in Care at level 4 and, on completion of that course, planned to start her management course at NVQ level 4. As mentioned in Standard 33 of this 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 21 report, the Manager had spent very little time in the Home since its reregistration in April 2007. This appears to have contributed to staff feeling the need for better communication with managers above Deputy Manager level – for example, feeling they received limited support with completing the newly introduced Medicine Administration Record sheets. Also, one service user said, of the Manager, “She is always busy...spends no time with me”. The Support Manager explained that the Manager was spending more of her working week managing the other local care home re-registered with the same Registered Provider in April 2007. The relative, who responded to the Commission’s postal survey, felt that the Home could improve the communication it has with relatives - with regard to having been promised a meeting with the new Provider and Manager but she was still waiting for this. The Home’s Quality Assurance monitoring folder was seen. There were also minutes of monthly service users’ meetings led by the Deputy Manager. These were a constructive record and included a note of action to be taken. Another useful set of documents were the ‘Monitoring Quality Assurance - Comments and Action’ sheets. These were constructive records and made reference to the ‘Service Users’ Quality Questionnaires’ that were being completed periodically. The latest ones were dated August 2007. These were examined and showed positive responses from service users, although they did not cover a particularly wide range of topics. The Support Manager stated that there were plans to send quality questionnaires to relatives, staff and external professionals too. The relative, who responded to the Commission’s postal survey, stated that, “the carers are wonderful…I cannot thank them enough, they are great”. There was no annual plan in place. There was no evidence of any monthly independent audit visits to the Home, on behalf of the Registered Provider, having been undertaken. The Deputy Manager said that staff meetings had been held on 14 May and 13 June 2007. Service users’ meetings were held at least monthly, she added. All the written policies and procedures in place were developed by the previous providers. They were mentioned by name in a number of these policies. Mention has already been made in this report of policies/procedures that need improvement. The Support Manager said new ones were being drawn up. Fire precautions taken by the Home included weekly alarm tests, periodic checks of two fire extinguishers and one fire blanket, fire training and monthly fire drills. There were also annual portable appliance tests. Records of all these were in place. Accident/incident records were in place. The First Aid box was kept in the laundry room and its contents regularly audited. Good food hygiene practices were noted including safe food storage and refrigerator and freezer temperatures recorded regularly. The Environmental Health Officer had visited the Home in May 2006. He had made two minor recommendations that had both been met. The Fire Officer had confirmed in writing that he would not be routinely inspecting the Home. A good range of environmental risk assessments were in place. There was evidence of these being regularly 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 22 reviewed, including by the service users. There was no evidence of tests being made of gas appliances within the past 12 months or of the property’s electrical wiring being tested within the last five years. Cleaning materials were being secured stored in the utility room. Product data sheets, required by the Control Of Substances Hazardous to Health (COSHH) Regulations, were not in place. 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 23 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 3 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 3 33 3 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 3 X 2 X 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 24 N/A 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 YA20 Regulation 13(2) Requirement Timescale for action 01/10/07 2. YA34 19(1)(b) Schedule 2 3. YA35 13(3) 4. YA37 9(1) 9(2)(b)(i) When medicine is provided to service users, for their use, it must be from the container that the pharmacist has provided. This container must have the name of the service user on the label, to ensure that the person receives the correct medication. Staff must not be employed 01/10/07 unless required information and documents, relating to their recruitment, are in place. This is necessary to ensure the safety of service users. All staff who handle food must 01/01/08 be provided with Basic Food Hygiene training to ensure the health and safety of service users is not compromised. The Manager must have the 01/04/08 necessary competencies to meet the needs of the service users at the Home, in order that the objectives set out within the Statement of Purpose can be achieved. This must be through the attainment of an appropriate qualification in ‘Care’ at NVQ level 4 and commencement of a management qualification at DS0000069782.V341948.R01.S.doc Version 5.2 68 High Street Page 25 NVQ level 4. 5. YA37 10(1) The Manager must spend enough 17/09/07 time at the Home to ensure that it is managed with sufficient care, competence and skill. This must include the supervision of staff. Monthly independent audit visits 01/10/07 to the Home must take place, to ensure the Registered Provider is kept aware of the Home’s conduct. Gas appliances must be serviced 01/12/07 annually, and electrical wiring checked every five years, to ensure their continuing safe operation and the safety of service users and staff. 6. YA39 26 7. YA42 13(4)(a) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA1 YA1 YA2 Good Practice Recommendations The Home’s Statement of Purpose should contain all the items listed in Schedule 1 of the Regulations. The Home’s Service Users Guide should be in a format suitable for the individual service users. The Home should review its policy/procedure on the admission of a new service user, making explicit the need for a full assessment of need to be available before admission. The Home should be working towards providing all documents, to which service users should have access, in an ‘easy read’ format. Care planning documents should also reflect a ‘person-centred planning’ (PCP) approach. Health Action Plans should be developed. Handwritten entries on medicine records should be accompanied by two staff signatures and the date, to ensure a clear audit trail. A record of specimen staff signatures/initials should be introduced, to ensure a clear audit trail. DS0000069782.V341948.R01.S.doc Version 5.2 Page 26 4. YA1 YA6 YA22 YA19 YA20 YA20 5. 6. 7. 68 High Street 8. 9. 10. 11. YA20 YA23 YA33 YA34 12. 13. 14. 15. 16. 17. 18. 19. YA35 YA35 YA37 YA39 YA39 YA39 YA40 YA42 There should be a written procedure covering the safe use of ‘as and when required’ medicines. The Home’s ‘Adult Protection Procedures and Prevention of Abuse’ should be amended to fully reflect safe practices. The staffing rota should include the Manager’s hours. Written references of a ‘To whom it may concern’ type should not be accepted without verification as to their authenticity. Requests for written references should be made by the Home to the people named by applicants. Staff should receive induction training to the Skills for Care Common Induction Standards. Staff should be provided with specialist training on epilepsy. The Manager should be undertaking training to increase her knowledge and skills in caring for people with a learning disability. The format of ‘Service Users’ Quality Questionnaires’ should be reviewed so that a wider range of topics is covered. Quality questionnaires should be sent periodically to relatives, staff and external professionals, as well as service users. An annual plan should be developed, covering all aspects of the running of the Home. New written policies and procedures should be developed. Product data sheets, required by the Control Of Substances Hazardous to Health (COSHH) Regulations, should be in place. 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 68 High Street DS0000069782.V341948.R01.S.doc Version 5.2 Page 28 - 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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