Inspection on 19/03/07 for 75 Hightown Road

This inspection was carried out on 19th March 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

75 Hightown Road 06/09/07

75 Hightown Road 21/12/05

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Dalewood Respite Care

Orchard,The

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Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 75 Hightown Road Ringwood Hampshire BH24 1NH Lead Inspector Tracey Horne Unannounced Inspection 19th March 2007 08:30 75 Hightown Road DS0000064991.V327535.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 75 Hightown Road DS0000064991.V327535.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. 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 75 Hightown Road Address Ringwood Hampshire BH24 1NH 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) 01425 461269 www.c-i-c.co.uk Community Integrated Care Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st December 2005 Brief Description of the Service: This home is registered to provide care and accommodation for four service users who are young adults and have a learning disability. The responsibility for managing this service has been taken over since the last inspection by Community Integrated Care (CIC). The property is leased from Hampshire Voluntary Housing. The home is currently being managed by an acting manager following the registered managers resignation. Accommodation is provided in a large family home, situated in a quiet residential area. It is close to local amenities, shops and public transport. Service users each have their own room on either ground or first floor and share two bathrooms. Access to the first floor can be gained by one flight of stairs. There is a large lounge, dining room, conservatory and kitchen/diner and an enclosed pathed garden. The acting manager confirmed the home charges a standard tariff, which is £1,025.91 per week. 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards and Regulations. The findings of this report are based on several different sources of evidence. These included: an unannounced visit to the home, which was carried out on the 19th March 2007 between 08.30 and 14.30, during which the inspector (Mrs Tracey Horne) was able to have discussions with the staff on duty. Due to the specific needs of the service users it was difficult to talk to everyone living at the home, but observation enabled the inspector to gain a better understanding of how the needs of service users were being met. The opportunity was taken to look around the home, view staff and care records and procedures. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection. Despite a reminder letter from the Commission to the provider, the Pre Inspection Questionnaire (PIQ) was not returned to the CSCI prior to this inspection, it was supplied after this visit. Surveys which had been sent to the home for service users, staff and relatives to complete had not been returned to the commission. What the service does well: The staff are caring, respectful and are mindful of peoples need for privacy and dignity. They encourage individuality and independence within the limits dictated by the service user’s needs. The staff support individuals to make decisions about their lives. Service users are offered a variety of foods, fresh fruit and vegetables and lots of choice to enable a balanced, varied and healthy diet. All of the meals are freshly prepared. The home has a process for recruiting new staff which safeguards the people living in the home. The staff team have a good rapport with service users. The staff on duty during this visit stated that they were supported by the management to do their job. 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: As a result of this visit, 4 requirements and two recommendations were made, mainly regarding record keeping. Care plans must show that the individual service user (or their representative) has been involved in the reviewing of care plans, to ensure the content is relevant to the care and support needed by the individual. Risk assessments must be reviewed regularly to show that risks have been identified and action has been taken to minimise risks to service users and staff. Recording of administered medication must be improved to ensure and safeguard service users health care needs. The bath in the ground floor bathroom needs to be replaced, to enable service users living on this floor to have a bath (as this is identified in their care plans as their preference.) The acting manager said service users access the complaints procedure which is held electronically on the computer as part of the service users guide, therefore service users can only access the complaints procedure when staff are available to access the office where a computer is held. Service users would benefit from being able to access the complaints procedure for themselves in a format, which meets their needs. The complaints log could be improved to include details of the date when a complaint is made, the date action was taken, by whom and the outcome. This would provide an easy audit trail for the home to monitor complaints. The acting manager would benefit from training and support to run the home effectively. Service users are given a choice regarding meals, however further improvement is needed to ensure individuals maintain a varied, balanced diet. 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 7 Service users would benefit from staff achieving a National Vocational Qualification award. The dining room needs to be decorated and a new carpet fitted to provide an improved environment for service users to eat their meals. 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. 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory admission procedure that is followed to ensure that placements will only be offered to service users whose needs can be met. EVIDENCE: The current service users have lived in the home since it was opened. The acting manager said she thinks the assessment paperwork that was carried out with each service user has been archived, as it was completed years ago. The acting manager said that although she has no experience of assessing or admitting a new service user, she said she felt the most important aspect of a new service user moving in would be that they fitted in with the current service users and that the service could meet their needs. The acting manager said the organisation Community Integrated Care (CIC) is currently updating the home’s policies and procedures, and she showed the inspector a copy of the homes assessment and admission policy. She stated she would follow this procedure, and obtain advice and support from her line manager to ensure this process is carried out thoroughly. The acting manager said one service user is currently in hospital, and she would ensure this assessment process is carried out before the serviced user returns home to ensure the home is able to meet the individual’s needs. 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While care plans and risk assessments were completed and in place, they were not regularly reviewed in order to ensure that the changing needs of service users would be identified and met. Service users are supported to make decisions in their lives. EVIDENCE: The inspector looked at two care plans and the records showed that the care plans were last reviewed in June 2006. There was no record of service users being involved or consulted regarding the care plan content, therefore a requirement was made to ensure that care plans are reviewed regularly with service users involvement. Care plans included details of individual’s care and support needs, and most included details of how staff are expected to ensure these needs are met. There was information about individual’s personal interests, religious beliefs, family relationships, details of friends and important people in service users lives, any specialist equipment, likes and dislikes and communication. Some 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 11 information was not correct, for example, one care plan stated the service user had a ‘sore left ankle’. The acting manager said this occurred some time ago and is not the case at this present time. Another care plan stated the service user was unable to watch TV in their bedroom as their TV was broken. The acting manager said the service user had bought a new TV, therefore this was also inaccurate. The care plans held a lot of information in them, some was relevant, and some was out of date. For example, old risk assessments were in the care plans and could be confused with current ones. One service users care plan clearly stated that the service user has no verbal communication, however, guidelines of how the individual communicates in other ways, eg, facial expressions, hand gestures and making noises, was found at the back of the care plan. This is not helpful to the new staff that have recently been recruited and does not ensure the service users needs are met. The home operate a ‘keyworker’ system, which means each service user has an allocated member of staff who carries out specific responsibilities, for example completing care plans, assisting with shopping for clothes and toiletries. The acting manager said she would discuss the requirements regarding care plans and risk assessments with all staff. Each care plan had a leaflet which explained how to access advocacy services should any service user need to. At the time of the inspection the acting manager said no service user was accessing this. The inspector looked at risk assessments that covered all identified areas of risk for activities within and surrounding the home (such as awareness of stranger risk). Not all records seen showed that they had been reviewed regularly, for example one risk assessment for a service user having a bath stated that the service user has epilepsy, the risk assessment had not been reviewed since November 2004. The home’s generic fire risk assessment had not been reviewed since May 2005, therefore a requirement was made to ensure risk assessments are up to date and reviewed regularly. 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 service is increasing the support for individuals to take part in age appropriate activities within the home and local community. They encourage appropriate personal, family and other relationships whilst respecting individual’s rights and dignity. The home are improving the way service users are able to choose what meals they want, however further improvement is needed to ensure service users maintain a balanced and varied diet. EVIDENCE: Individual preferences regarding activities and cultural beliefs are recorded in their care plans and daily activities are recorded in individual’s daily notes. These ranged from attending a day centre, Women’s Institute, and attending a luncheon club. One service user chooses to go to church every other week and has various days out at the weekends. One service user’s care plan stated they are interested in aeroplanes and the records showed the service user has been 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 13 to airports to watch the planes. One service users care plan stated that the service user did not like going to places where there are a lot of people, they enjoy going shopping. The staff support the service user to visit a small local shop which sells all items the individual requires. It was discovered in one service users review that they wished to try horse riding and the acting manager said this is being explored. On the day of the inspection two service users were attending a day centre while one service user was being supported to eat their breakfast and then they went shopping. The acting manager said they encourage regular contact with family members, the visitors’ book and daily records reflected this. The acting manager said that only service users who wished to help with housework or shopping did so. Where a service user liked to help, this was recorded in the care plan so staff were aware of what activities the service user liked to do. For example, one service user liked to listen to the noise the hoover makes. The inspector asked if the service user has ever participated in hoovering, the acting manager said this may be something they could introduce. Individual service users daily activities are detailed in picture format on a timetable. The acting manager said the home have recently recruited two staff who will eventually be able to support service users attend activities. The acting manager said that the home no longer plan a menu, as she hopes service users will have more choice on a daily basis if there is not a set menu. Records kept and sampled since the menus have been abolished showed a lack of variety, for example, during the previous week, the meat in every main meal was chicken. The acting manager said this has highlighted a training need for staff to ensure a varied and balanced diet. The acting manager said she has requested a freezer is bought to allow further storage of foods to promote and improve choice and availability, so on this occasion a requirement was not made. The cupboards and fridge were stocked with foods. Care plans indicated individuals likes and dislikes in relation to foods, however as they had not been reviewed for some time and therefore it was not apparent if this is still the case. 75 Hightown Road DS0000064991.V327535.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. 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. Although service users receive support in a way that they prefer, the care plans need to be reviewed to ensure information regarding preferences is current. Staff follow the home’s health and welfare procedures to ensure service user’s physical and emotional health needs are met, however records of this need improving. Service users are mainly protected by the homes medication policies, but certain procedures must be improved. EVIDENCE: Staff spoken with were clear about each person’s individual preferences as they had worked with the service users for some time, and know them well and said service users are able to communicate their wishes with them. Care plans did not always show how individuals prefer to communicate and they had not been reviewed regularly to show that the needs recorded were still relevant to the service users preferences. 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 15 One Service users was at the home during part of the visit and was observed choosing to spend time with staff. Care plans were not clear for the inspector to track individual’s visits to healthcare professionals, such as the doctor or dentist. For example, on a scrap of A4 paper, a member of staff had recorded that they noticed a bruise on a service users hip, there was no other record of this in the accident book. The acting manager said the previous manager contacted the service users doctor, the service user had X-rays taken and returned to see the doctor one week later to get the results. Again, no records were available at the time of this visit to confirm this. The inspector read the home’s contact sheet, which detailed an incident, which occurred when a service user was waiting to be collected to attend their day placement. The day centre staff witnessed the service user fall and contacted the home by telephone to inform them of the incident which occurred just outside the home. The acting manager said agency staff were on duty that day. The inspector read a record (on a piece of scrap A4 paper) which described staff noticing a swollen area on the service users hip. The member of staff (who did not sign the record) stated ‘I will be keeping an eye on her through the night,’ however no records were available to show checks had occurred. The acting manager said one service user was having frequent falls, and she tried to obtain support from healthcare professionals to provide additional equipment to aid the service user, such as a bed and hoist. The service user was admitted to hospital recently following a fall and the acting manager said that she did not feel that the home would be able to meet the service users current needs without any specialist equipment. The inspector looked through the Medication Administration Sheets (MARS) there were many gaps where staff had not signed to say the service user had received their medication, therefore a requirement was made. The inspector saw the home’s medication storage cupboard that was clean with medication stored correctly in date and in sufficient quantities. One member of staff said that they had received training in the safe administration of medication, training certificates confirmed this. Staff confirmed that at the time of the visit, no service user self medicates their medication due to the level of support required. 75 Hightown Road DS0000064991.V327535.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. 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. Arrangements for protecting service users and responding to concerns are satisfactory, however the procedure for recording complaints could be improved. EVIDENCE: The home has a formal complaints log, which was empty. The inspector recommended the log include details of the date when a complaint is made, the date action was taken, by whom and the outcome. This would provide an easy audit trail for the home to monitor complaints. Staff said they were aware of the homes procedure for dealing with complaints efficiently. The home have improved its complaints procedure into a format to meet service users needs, however it is in audio/visual format as part of the service users guide, and can only be accessed by the computer in the staff office. The acting manager said that the home’s policies and procedures were being revised, and these have not yet been filed into the appropriate policy and procedure file. Staff said they were aware of the procedure to follow should an allegation or suspicion of abuse occur. 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 17 The staff said that they receive training in the prevention of abuse of vulnerable adults and training certificates confirmed this. The inspector looked at the financial records of two service users who live in the home, both were found to be correct when checked against money held. 75 Hightown Road DS0000064991.V327535.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from some areas of the home being refurbished to provide a homely, comfortable and safe environment to live in, however one bathroom is not sufficient to meet the identified needs of service users. The home is clean and hygienic. EVIDENCE: The inspector looked around the communal areas, which were clean with no offensive odours detected. The acting manager said she has asked her manager for permission to decorate the home. Staff explained service users are encouraged to choose the colour scheme for their bedrooms and furnish the room with personal belongings, furniture and pictures to make it feel like home. This was confirmed through observations during the visit. 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 19 The home has a secure courtyard garden, staff said they have discussed growing vegetables in pots with service users. The bath in the ground floor bathroom is not in working order, and this was also noted during the last inspection dated 21st December 2005. This is not meeting the needs of the service users who access this bathroom, as it is identified in their care plans that they prefer to have a bath rather than the shower they are using. Although the overall outcome for the environment has been assessed as good, the home must address this matter as soon as possible to ensure that service user’s assessed needs are met and that they have suitable and sufficient bathing facilities. A requirement was therefore made that the bath on the ground floor is repaired or replaced to ensure all service users have access to suitable bathing facilities in line with their preferences and care plans. The inspector saw that the dining room walls and carpet were worn and in poor condition. The acting manager said that the dining room carpet will be replaced and the walls will be painted as she had already requested this work be completed by the organisation. Staff said they have completed infection control training, and were aware of the home’s policies and procedures of hygiene issues. The inspector saw records of staff training and the member of staff who was cooking confirmed they were up to date with food hygiene training. The home’s radiators and pipe work are safe ensuring that all potential hot surfaces are kept to low temperature. 75 Hightown Road DS0000064991.V327535.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Competent staff support and meet the needs of service users but would benefit from further training in National Vocational Qualifications (NVQ). Service users are protected by the homes practices regarding the recruitment and selection of staff. EVIDENCE: Staff told the inspector they feel they have adequate training to enable them to do their job properly. Records of staff training reflect this and show staff have received training in adult protection, health and safety, manual handling, first aid, food hygiene, epilepsy, infection control, epilepsy and fire awareness. The pre inspection questionnaire stated that 25 of staff are either working towards or have achieved NVQ level 2 & 3, the standard required 50 should be achieving an NVQ level 2 or above. The acting manager said this shortfall may be due to the staff changes that have occurred recently and the registered manager has resigned. 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 21 The home has a suitable recruitment and selection procedure in place and the records of two staff demonstrated that this was followed appropriately. All staff had the necessary checks prior to beginning work in the home. The home has recently recruited two full time staff and has one full time vacancy remaining, which a member of bank staff is interested in applying for. The acting manager confirmed that staff work to the Learning Disability Award Framework (LDAF) induction standards in line with national guidelines for good practice. Staff said that a minimum of two staff are on duty and that any one-to-one hours needed to support service users are covered by bank staff. The rotas showed that a minimum of two staff were on duty each day. This included the acting manager who said she has few hours a week to concentrate on the management aspects of the home. This needs addressing to ensure the manager has sufficient time allocated to full fill her managerial role and that the home is managed appropriately. Staff provide sleep in cover during each night shift. At the time of the visit the acting manager said that service users do not need waking staff during the night. Adequate risk assessments need to be in place and be reviewed regularly to promote the safety of service users and ensure their needs at night are met or continue to be met. The staff undertake the cooking and cleaning with the service users assisting where possible. No separate ancillary staff are employed at the home. 75 Hightown Road DS0000064991.V327535.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,41 & ,42. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is being managed on a temporary basis by a person not fully qualified to do so, and improvements are needed to ensure that the home is run in the best interests of service users. EVIDENCE: The acting manager was, until three months ago, a senior support worker at the home. She stated that she had commenced the National Vocational Qualification Level 3 last year but did not finish it. The acting manager confirmed she does not have any formal care or management qualifications. A requirement was made to ensure that the person running the home is qualified to do so. 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 23 The acting manager works on shift with service users and staff for the majority of her working week and she stated that she does not have adequate time to manage the home, however she said she is receiving support from her line manager and said that this is a temporary arrangement until she decides whether she wants to apply to become the permanent manager of the home. During her time as acting manager she has identified the fact that the management of paperwork needs to be improved. She told the inspector “I am still getting to grips where everything is being kept.” The inspector asked the acting manager for the home’s completed pre inspection questionnaire (PIQ), as the CSCI requested the home complete this paperwork two months prior to this visit. The home did not provide the information required by the given date, despite a reminder and the commission has requested it be returned by the 23rd March 2007. During the inspection it was evident that the acting manager was not always aware of where the paperwork was kept for the inspector to see, this is also reflected in other areas of this report. One daily record stated a service user had fallen, this record did not co-inside with the accident book, and a regulation 37 notice did not appear to have been sent to the CSCI. The acting manager thought the accident form may have been sent to the head office, where accidents are evaluated. Therefore a requirement was made, and a recommendation was made for the acting manager to participate in training to enable her to carry out the role of managing the home effectively. The home arrange monthly staff meetings, one staff member said the majority of staff attend. Service users views are sought frequently, however this is not always documented. The provider has developed a quality assurance system which the home are going to using to gain views and opinions from the people who use the service. It was stated by the acting manager that a questionnaire will be sent to service users and their families/representatives. The responsible individual for the organisation completes monthly unannounced visits to the home as required to carry out a quality review of the service. A copy of these reports were available in the home. The staff are continuing to improve ways in which they can ensure service users views are obtained, they have introduced a wide range of pictures to encourage service users to communicate. The staff complete regular weekly health and safety checks to ensure the safety of the building. Certificates were seen to show regular servicing of the boiler, electrical items, fire safety equipment and liability insurance. All Control Of Substances Hazardous to Health (COSHH) sheet corresponded with the cleaning chemicals used in the home. 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 24 Records of staff attending fire training and practices were available and showed all staff attended in January ’07. The inspector asked if night staff receive training at night, as only one member of staff is on duty. Following discussion, the acting manager stated that she would check the fire safety training for night staff as she could not confirm this on the visit. 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 1 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 x 2 X 2 X 2 2 x 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 26 No 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 YA6 Regulation 15.2(c,d) Requirement Care plans must include the support needs for service users, be reviewed regularly and be signed by the person undertaking the review and the service user and/or their representative, to demonstrate service users and staff are aware of service user needs. Risk assessments must be updated and reviewed regularly, to show that risks have been identified and minimised, to ensure the safety of people living and working in the home. A signed record of the time and date on which prescribed medication was administered to service users must be maintained. The bath on the ground floor must be repaired or replaced to ensure all service users have access to suitable bathing facilities in line with their preferences and care plans. The person managing the home must be competent and qualified to do so. Timescale for action 19/05/07 2 YA9 13.4(b,c) 19/05/07 3 YA20 17(1) Schedule 3(k) 23.2(j) 19/05/07 4 YA27 19/05/07 5 YA37 9.1,2(b.i) 19/05/07 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 27 6. YA41 17.1,3. Records required to be kept in the home must be up to date, accurate and available for inspection. 19/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA22 Good Practice Recommendations The complaints log should include details of the date when a complaint is made, the date action was taken, by whom and the outcome, as this would provide an easy audit trail for the home to monitor complaints. 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 29 75 Hightown Road DS0000064991.V327535.R01.S.doc Version 5.2 Page 30 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!