Inspection on 16/08/06 for 72a Broad Street House 1

This inspection was carried out on 16th August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

72a Broad Street House 1 27/04/09

72a Broad Street House 1 25/04/07

72a Broad Street House 1 19/01/06

72a Broad Street House 1 06/06/05

72a Broad Street House 1 20/12/04

72a Broad Street House 1 08/07/04

72a Broad Street House 1 13/01/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 72a Broad Street House 1 Ash And Birch Units Clifton Shefford Bedfordshire SG17 5RP Lead Inspector Ian Dunthorne Unannounced Inspection 16th August 2006 14:00 72a Broad Street House 1 DS0000014884.V297540.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 72a Broad Street House 1 DS0000014884.V297540.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. 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 72a Broad Street House 1 Address Ash And Birch Units Clifton Shefford Bedfordshire SG17 5RP 01462 814196 01462 850689 pauline.jarman@hft.org.uk www.hft.org.uk Home Farm Trust 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) Pauline Jar man Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: 72A Broad Street (Ash and Birch) was a purpose built house owned by Home Farm Trust situated in a site recessed from the main street in the village of Clifton. On the same site was a second house provided by HFT for eight people with learning disabilities and the two houses shared a common paddock in addition to their individual gardens. The house was divided into two units namely Ash and Birch, each with a lounge, dining room and kitchen. One unit catered for people with Prader-Willie syndrome and the other for people with complex communication needs. Each service user had a single bedroom. In each unit were two bathrooms and a shower room with a total of seven toilets between the two units. Staff were provided with a room with en-suite facilities, which was also used as the main office. This room was situated between the two units and formed the link on the first floor between both units. The ground floor link was the communal laundry. The homes current scale of charges was not provided. However the fees payable did not include newspapers, hairdressers, personal telephone, toiletries or private chiropodist; these services would incur an additional charge. 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over nine hours during two afternoons and early evening and it was unannounced. Prior to the inspection time was taken to review the information gathered since the last inspection and plan this inspection visit. This report also includes feedback from relatives, visitors and service users obtained from postal comment cards. The inspection included a tour of the communal areas and several bedrooms, inspection of certain records, discussion with staff and the manager, discussion with service users and observation of the routines of the home. No relatives were available during the inspection to speak with. The method of inspection was to track the lives of several service users. This was done by speaking to them about the service they receive, observing their life in the home, talking to staff and relatives and reviewing their records. What the service does well: What has improved since the last inspection? The home ensured that all staff employed had the appropriate employment clearances and checks in place, which made sure they were suitable. The home and the manager were supported by employing additional senior staff. 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 6 Contracts and care plans in suitable formats for service users to understand were being introduced. What they could do better: Some of the things that the home could do better include: • Asking for the views of service users and others about what they think of the home and any suggested ideas for improvement. Then producing a plan, showing how they will act upon those views and carry the plan out. Making sure that service users have a written contract and that they are clear about anything they will have to pay for. Ensuring that medication is properly looked after and that measures are in place to ensure it does not go out of date. Providing training for staff, which would help them understand and meet some of the specialist needs of the people living at the home. Making sure that service users or their families are involved in preparing information about them, to help the home meet their needs. Then checking the information regularly and making any changes needed to it. Making sure that service users money is looked after in a safe and secure place. • • • • • 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. 72a Broad Street House 1 DS0000014884.V297540.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 72a Broad Street House 1 DS0000014884.V297540.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 ‘Quality in this outcome area was adequate. This judgement was made using available evidence including a visit to this service.’ Some information about the home wasn’t always readily accessible and there was no information telling prospective service users how to access it, which limited them from making a fully informed choice about the home and living there. Contractual agreements were provided for most service users and in a suitable format; however they failed to identify the fees payable, which did not allow service users to be aware of the fee and what they may need to pay. EVIDENCE: The homes service user guide was available in a suitable format for the service users intended and provided information to enable prospective service users to make an informed choice about where to live. The homes last inspection report was available within the home, but only accessible upon request. The manager explained that this was because some service users may remove the inspection report if displayed. However there was no evidence at the time of the inspection, demonstrating that service users, relatives and visitors had been informed of this, or any document telling them how they could access the last inspection report. Responses from the relatives & visitors comment cards reflected that some did not know how to access the last inspection report for the home. No new service users had been admitted since the last inspection. Therefore this standard could not be fully assessed. However there was evidence 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 9 included within the records of the service users whose lives were tracked, which supported that the home had undertaken a full assessment of needs for each of them. The needs assessment was also supported by a health and social services assessment. The home had developed a service user plan from the assessment of needs. There was evidence that two out of three service users whose lives were tracked had written contracts with the home, which included a statement of the terms and conditions. There was no evidence of a contractual agreement with one of the three service users. There was evidence that the home had begun to introduce contracts in a format appropriate to the needs of the service users. The home had failed to include fees charged within the terms and conditions. 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 ‘Quality in this outcome area was adequate. This judgement was made using available evidence including a visit to this service.’ Service user plans contained satisfactory information, however further development was needed to ensure both the plans and risk assessments were reviewed and updated at regular intervals. To ensure they accurately reflected service users changing needs and associated risks to enable the home to meet those needs and minimise risk to service users. EVIDENCE: A sample of the service user’s plans and supporting documentation were examined and found to contain suitable and sufficient information to help meet their changing needs and personal goals were identified and reflected in their individual plan. The plans included individualised procedures for service users likely to be aggressive, focusing on positive behaviour, ability and willingness. However there was inconsistent evidence that the service user, their family, friends or advocate had been involved in completing the plans and only some were available in a suitable format which the service user could understand, not all. There was evidence that the plans had been reviewed, although this had not been achieved at suitably regular intervals. 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 11 There was evidence from speaking with service users and records examined that service users were assisted as necessary to make decisions about their daily lives. Service users were supported by staff to participate in an advocacy service provided if they wished. Some information provided by the home was in a suitable format to support service users to make decisions about their lives and a different method of communication support was observed from staff with one service user to enable them to make a decision. It was evident by observation, that service users were offered the opportunity and participated in the day to day running of the home and contributed towards any proposed changes within the home, to influence any decisions reached. One service user said, “It’s our say it’s our home”. There was not always sufficient recorded evidence to demonstrate that service users were supported by the home to take responsible risks. One example was a risk assessment for a service user to launder their clothes, using the homes laundry facilities that referred the reader to see ‘guidelines in place’. However these guidelines did not accompany the risk assessment and staff were not directed to where they were and it was unclear what support the service user needed, or indeed what the staff should provide. In addition a ‘key’ to the risk assessment scoring system did not accompany the risk assessment, so it was difficult to establish what level of risk the score implied. There were risk assessments in place as part of the homes risk assessment strategy to enable service users to take risks supported by staff, however some had limited value because several of those examined had not been regularly reviewed. The home had identified on some risk assessments that they should be reviewed in six months, however this had not been done and they were over six months overdue for review and in several cases even longer, despite the risk changing during this period. 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 ‘Quality in this outcome area was good. This judgement was made using available evidence including a visit to this service.’ Service users were offered a healthy diet and were well catered for with a balanced and varied selection of food available, which met service users tastes and choices. EVIDENCE: The home supported several service users to attend a local college twice weekly and many were also supported by the home to regularly visit a local resource centre, which provided planned educational and training activities. Several service users spoken to said they were supported by the home to attend church when they wished to at times they wished to. Staff were observed supporting those service users who wished to, to go shopping during the evening in the local community, which demonstrated a flexible approach to their support. There was evidence that the home supported service users to maintain family links and friendships inside and outside the home, in accordance with their 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 13 wishes. One service user said “my visitors can come at any time and they can visit me in my room”. The evidence from speaking with some service users was that the service users were treated with respect and their right to individual choice was upheld and this was consistent with the service users, relatives and visitors comment card responses. One service user commented that staff would never walk into their bedroom, toilet or if they were in the bathroom without knocking and asking if they could come in. Service users were able to lock their bedroom doors if they wished and unrestricted access to the homes grounds unsupervised, was dependent upon the service users individual risk assessment basis. Service users were observed during a mealtime enjoying well prepared and presented, home cooked and appetising food in suitably sized portions. Service users were observed enjoying their meal and the mealtime itself which they had participated in preparing for, by planning the menu for the week, shopping and laying the table. There were no set mealtimes as such, as the service users preferred the flexibility. The menu’s choices were in a suitable format for service users to make an informed choice and decide what they would like to eat. Some service users nutritional needs were closely monitored and assessed, including associated risk factors. There was evidence that the home managed service users nutritional and associated behavioural needs well. 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 ‘Quality in this outcome area was adequate. This judgement was made using available evidence including a visit to this service.’ The systems for the administration of medication were satisfactory. However further development was needed to ensure that the date life of medications were identified and suitable management of eardrops were maintained, for service users medication needs to be met safely. EVIDENCE: Service users spoken to said they enjoyed living at the home, and although restrictions were placed on some service users, they appeared to understand the reasons why. The reasons for the restrictions are explained and recorded. Records viewed suggested service users received personal support in the way they preferred and most were encouraged to maximise their independence. This was supported by observations and discussions held with service users. One recently appointed male staff member was providing personal support to service users of the same gender, as this was their choice where possible. There was evidence that the home accessed outside healthcare professionals and services as required; in order to meet the healthcare needs of the service users. In addition the home was supported by a variety of healthcare services, accessible through a local resource centre. As a result of this for example, some service users attended regular hydrotherapy sessions. Medical visits 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 15 were being recorded separately to daily notes and a variety of healthcare monitoring charts were in use. The home had ensured all care staff were trained in medication and the procedures implemented suggested that service users safety was being maintained in most areas. One service users insulin that was being drawn up in advance, that had previously highlighted some concerns now demonstrated some safer practices. However, each individual insulin syringe did not identify the batch number from which they had been drawn up. The medication administration records (mar) were fully completed and no gaps were found when entries should be made, indicating that all medication had been administered in accordance with the stated instructions. Some eardrops and a bottle of liquid medication were found undated when opened, which prevented the home from knowing when they would be out of date and therefore unsuitable to continue administering. In addition further development was needed to ensure eardrops were being stored and managed appropriately. There was no method available to identify staff’s initials on the medication administration records. Some handwritten amendments had been made on the ‘mar’ sheet to the time of administration of one service users medication. However there was no evidence to support that this had been done in consultation and in agreement with the GP. Handwritten entries had been made to the ‘mar’ sheet in some instances due to poor printing by the pharmacy and handwritten entries made by staff had not been signed, dated or countersigned. The home did not have any service users receiving any controlled drug medication at the time of the inspection; therefore those aspects of this standard could not inspected. 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 ‘Quality in this outcome area was adequate. This judgement was made using available evidence including a visit to this service.’ The arrangements for protecting service users were satisfactory. However, further development was needed to ensure service users money & valuables were stored safely to protect service users from possible abuse. EVIDENCE: The home had a satisfactory complaints procedure that ensured service users felt their views were listened to and acted upon. The complaints procedure was produced in a format appropriate for service users to understand and access. There had been two complaints since the last inspection, evidence demonstrated that both were managed adequately and complied with their policy. One service user spoken to said they knew if they weren’t happy, they could fill in a complaints form or talk to the advocacy service. The home had a Protection of Vulnerable Adults (POVA) policy in place, which included whistle blowing and staff spoken to said they were aware of the procedure. Most staff had also attended abuse awareness training, which included POVA. Since the last inspection there had been three notifiable incidents in accordance with the POVA policy and guidance, which were reported to CSCI at the time. Evidence examined, supported a process that had been followed to safeguard and protect service users. Two of the three notifiable incidents were as a result of physical and verbal aggression demonstrated by two service users towards each other. However very few staff had received control and restraint training and those who had attended training several years ago. The manager said that the provider had a ‘non restraint’ policy and that consequently the home receives information and 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 17 specialist training from a specialist, which helps to support staff to deal with such incidents without using control and restraint. The manager was in the process of re-writing one service user’s plan to reflect this specialist guidance and subsequently help to support and enable staff to support the service user. The home was also supported by a specialist resource in Bedford, to help them manage volatile situations between service users. Records were maintained and the incidents were monitored closely by the home. There was evidence that actions had been taken and implemented to help prevent and avoid future situations which may provoke incidents, to protect service users safety. The homes policies and practices regarding service users money and financial affairs were generally satisfactory and protected service users from abuse. However, this did not extend to the storage of service users money, which was inadequate and unsafe for the amount of money & valuables being held accumulatively, on behalf of the service users. 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 30 ‘Quality in this outcome area was good. This judgement was made using available evidence including a visit to this service.’ The standard of the environment within this home was good, providing service users with an attractive and homely place to live in which suited their needs. EVIDENCE: The home provided a purpose built, comfortable environment for service users, which was free from offensive odours with cheerful and well-maintained decoration and furnishings. The home was close to local amenities and transport if required. One service user said that they had everything they needed and wanted in their bedroom. Another service users bedroom was observed to reflect their needs and lifestyle. All rooms were single occupancy with en suite provision. Service users spoken to were clearly happy with their individual bedrooms and they had free access to them and were encouraged to take responsibility to maintain their cleanliness. Toilets and bathrooms were safe and suitable for their intended purpose and were in appropriate locations. Each were lockable and maintained service users privacy, however staff were able to override this feature in an 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 19 emergency. Each bedroom provided en suite facilities. A new bath had been fitted downstairs, which was suitable to meet service users needs. The homes outdoor space appeared adequate, but was not fully accessible to all service users, the reasons for which were explained and recorded and was to protect their own personal safety. Kitchen and laundry facilities were suitable and domestic in scale. The laundry was a lockable facility with entry gained by service users with the supervision of care staff, due to ‘Control of Substances Hazardous to Health’ (COSHH) risk assessments and control measures in place to protect service users from harm. Staff were provided with suitable sleeping facilities when sleeping in. The home appeared clean and free from offensive odours, service users, care staff and night staff were responsible for ensuring this was maintained. However some communal toilets and bathrooms within the home had a communal towel in as the only facility to dry your hands on after washing them. This was not an effective infection control system that was consistent throughout the home, because in the remaining facilities disposable paper towels were provided. 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 ‘Quality in this outcome area was poor. This judgement was made using available evidence including a visit to this service.’ The arrangements for staff induction and some aspects of specialist training needed to meet the needs of the service users were poor. This placed both service users and staff at risk of possible harm, as a result of potentially limited information and knowledge provided to them, which could prevent them from carrying out there job safely & effectively. EVIDENCE: Staff spoken to identified varied training which they had undertaken at the home and this was supported by evidence in their training records. Although there was limited evidence that training in some service users specialist needs had been provided. For example, three service users out of seven were diabetic, however there was insufficient evidence to support adequate staff training to meet service users needs in this area. The guidance produced by the home to support those service users to manage their diabetes, did not accurately reflect the homes practices in reality. Several service users had ‘Prader-Willie syndrome’, although there was no evidence to support any training for staff in this area. However, the manager stated that some internal training had been provided in the form of a video, some brochures and an in depth talk as part of their induction; but acknowledged that this could not be evidenced and did not form part of any formal type of accredited training. 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 21 Approximately a third of care staff equating to five, had achieved their NVQ level 2 or above and another third of staff were currently registered and working towards completing their award. Staffing level numbers within the home were maintained to meet the appropriate ratio based upon the needs of the service user, by regular use of agency staff, at least one on each shift. However the home was provided with regularly agency staff, which helped to provide a consistent service for service users. Staffing level numbers fluctuated based on how many service users were in the home, they sometimes reduced at the weekends particularly if several service users had gone away. Staff files that were examined, demonstrated that the home had obtained satisfactory checks and clearances on staff before their commencement. Although some staff records employed some time ago were held centrally and not in the home. They were however accessible which the manager was able to demonstrate. The same staff who were employed over four years ago did not have any evidence to support an induction on their files. The manager explained that the home had experienced some recruitment difficulties, which she felt was attributable to the rural area, shift work and unsociable hours. Induction training for new staff did not comply with this standard. One staff member employed over six weeks ago at the time of the inspection had not completed structured induction training within six weeks of appointment. This placed the service users and the staff member at risk. Staff spoken to and records examined, provided evidence that staff received regular supervision. 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42 ‘Quality in this outcome area was adequate. This judgement was made using available evidence including a visit to this service.’ Service users’ views were sought but there was no evidence that this changed how the home was run. Some aspects of the homes health & safety, safe working practice procedures and risk assessments, needed further development to ensure service users & staff would be protected from the risk of harm. EVIDENCE: The registered manager Pauline Jarman was present throughout the inspection. The manager said that she had achieved NVQ level 4 in care, an HNC in management, NVQ assessors award and she had two units to remaining to complete of her ‘Registered Managers Award’. The manager was observed to communicate effectively with both service users and staff and appeared approachable. Service users and staff who were spoken to supported this view. The home had an inclusive atmosphere. The manager of the home maintained an effective leadership ethos that both service users and staff were able to benefit from. The manager said that 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 23 regular meetings were held with service users, their family and friends of the home, although evidence of this was not examined. The manager also said that the home had a lot of input and support from families, which was encouraged, however the manager acknowledged that this was not formally recorded in any way. Despite this one response to a relatives and visitors comment card, stated that communication could be improved and that often they were only informed of significant events after they had happened. Developing and maintaining an effective quality assurance system within the home, was set as a requirement at the last inspection and had still not been fully complied with. There was evidence that the manager had made some progress since the last inspection but had yet to complete the full quality monitoring cycle, which could then be maintained systematically. Some aspects of the homes health & safety safe working practices, required some improvements to protect service users from potential risk or harm. There was some evidence observed within the home’s kitchens that safe food hygiene practices were not always being consistently maintained by staff. There was evidence in one downstairs bathroom of an openly accessible cleaning chemical. There was evidence in two bathrooms that communal toiletries may have been in use, however the manager said that service users had left them there accidentally. Water temperature record checks were examined for July and found to be too high in four separate areas on four individual occasions, all of which were accessible by service users. It was unclear whether this had been reported to the maintenance department for action. The risk assessments and guidance relating to service users being supported to use the laundry facilities were unclear. Therefore they required further clarification to ensure service users were protected from the risk of harm and to ensure staff were aware and clear about the support they should give; including what the control measures and limitations are to protect service users. There was evidence that the home maintained general risk assessments, including the kitchens, wheelchairs, walking and the homes vehicles. These risk assessments had been signed by staff to indicate that they had read and understood them. The risk assessments were also supported in several areas by ‘General Guidelines’ produced by the home, which staff had also signed. Various records were examined to support adequate compliance with the following safe working practices, regarding health & safety including; hoist and adaptation servicing & maintenance, fire tests / drills and accident records. The home used a system of generic ‘Control of Substances Hazardous to Health’ (COSHH) risk assessments. However, this information did not provide fully effective safe working practice guidance and therefore was not sufficient to limit risk to staff or individual service users, who may be risk assessed to use such products. 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 2 34 2 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 2 2 X X 1 X 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5 (1b) & (1c) Requirement Each service user must be provided with an individual written contract or statement of terms & conditions, which must include the amount and method of payment of fees. Service user plans must be prepared in consultation with the service user or their representative. Arrangements must be made to ensure all service users care plans are reviewed to meet the requirements of the standard. I Previous timescale 30/03/06 partly met. Risk assessments must be reviewed by the home at appropriate and agreed intervals. Arrangements must be made for insulin syringes, which are drawn up in advance, to have the individual insulin batch number from which they have been drawn to be recorded on the syringe. A method or facility of safe storage for service users money & valuables must be arranged. DS0000014884.V297540.R01.S.doc Timescale for action 31/10/06 2. YA6 15 (1) 31/10/06 3. YA6 15 (2b) & (2c) 31/10/06 4. YA9 13`(4a,b, c) & 15 (2b) 13 (2) 31/10/06 5. YA20 30/09/06 6. YA23 13 (6) 31/10/06 72a Broad Street House 1 Version 5.2 Page 26 7. 8. YA32 YA35 YA39 18 (1c,i) 24 91)(a) 9. YA42 13 & 23 10. YA42 13 & 23 Training must be provided for staff, which is appropriate for the work they are to perform. Arrangements must be made for the quality assurance system to be implemented in the home to review quality monitoring. Previous timescales: 30/06/05, 30/04/06. Water temperatures, which are being recorded above the safe regulated temperature, must be rectified. Generic COSHH risk assessments and risk assessments associated with services users accessing and using the laundry facility; must contain suitable and sufficient information to protect service users and staff from harm. 30/11/06 30/11/06 30/09/06 31/10/06 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. Refer to Standard YA1 YA5 Good Practice Recommendations The homes most recent inspection report should be made available to both service users and their families. The service users contract should be in a format appropriate to each service users needs and/or reasonable efforts have been made to explain the contract to the service user. Handwritten entries made by staff to medication administration records should be signed, dated and countersigned. Bottled liquid medications, ear / eye drops, creams should be dated when opened to accurately initiate date life once opened. A list of current staff initials trained to administer medication should be held within the home, for medication administration record identification purposes. DS0000014884.V297540.R01.S.doc Version 5.2 Page 27 3. 4. 5. YA20 YA20 YA20 72a Broad Street House 1 6. 7. 8. YA30 YA42 YA42 Disposable hand towels should be provided in communal toilets and bathrooms, to ensure effective infection control practices are not compromised. Safe food hygiene practices within the home must be maintained at all times. Service users should have access to their own toiletries when required. A system of communal toiletries should not be present within the home. 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 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 72a Broad Street House 1 DS0000014884.V297540.R01.S.doc Version 5.2 Page 29 - 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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