Inspection on 19/09/05 for 7a Finborough Road

This inspection was carried out on 19th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

7a Finborough Road 26/01/09

7a Finborough Road 23/02/07

7a Finborough Road 01/02/06

7a Finborough Road 10/03/05

7a Finborough Road 12/10/04

7a Finborough Road 24/10/03

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 7a Finborough Road 7a Finborough Road Short Break Service Stowmarket Suffolk IP14 1PN Lead Inspector Deborah Seddon Unannounced Inspection 19th September 2005 2:06 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 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 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 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. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 7a Finborough Road Address 7a Finborough Road Short Break Service Stowmarket Suffolk IP14 1PN 01449 626205 01449 626205 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) Suffolk County Council Mr David James Gilbert Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th March 2005 Brief Description of the Service: Opened in 1995 as a short break facility, Finborough Road is registered as a care home for 4 adults with learning disabilities. Suffolk Social Services are the registered provider. Service users are expected to continue with their day care services during their stay at Finborough Road. The local social care services day centre closes for ten days per year and on these dates Finborough Road offers day care for service users during the day although no over night respite services are offered on these days. The home is situated close to Stowmarket town centre within a small cul-desac of buildings. There is a large driveway with a parking area shared by other buildings. The house has four individual bedrooms, two on the ground floor and two on the first floor. There is a spacious kitchen/dining room, which opens onto a patio area. The living room leads into a staff sleep in room which doubles as a duty office. A shower room, suitable for wheelchair users, separate toilet and laundry area are also on the ground floor. A wide staircase leads to the bedrooms upstairs, bathroom, toilet, storeroom and manager’s office. There is another patio area behind the laundry, which overlooks a pond. Towards the front of the building there are views towards the church. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 3.30pm. It took place over five hours during a weekday. Time was spent with the manager and acting manager to discuss how the previous requirements had been addressed and the future management of the service. There was only one service user with limited communication skills staying for respite on the day of the inspection and therefore the inspector concentrated on the management of the service. Two relief staff were on duty, both were spoken with and a number of records, policies and procedure, relating to users of the service, staff and management of the home were examined. What the service does well: What has improved since the last inspection? There were nine requirements made at the last inspection in March 2005; the service had met seven of the requirements. Regular monthly, unannounced, visits are now being undertaken by a social services care manager. This includes service user and staff feedback about the service, and a copy of the report is being forwarded to the commission for social care inspection (CSCI). A copy of the terms and conditions called service users agreements has been included in the service users guide, however copies of the agreements on service users files were out of date and need to be updated to reflect current fees being charged by the service. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 6 The service has implemented a range of detailed procedures and protocols, which include pressure care and continence promotion, and sharing of information with day services and relatives to maintain confidentiality. The service has implemented risk assessments to minimise identified risks with regards to manual handling, bedrails, wheelchair and personal assessments to manage continence and pressure relief. Although these assessments were very detailed, they had not been updated, to show if the information was still accurate. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 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 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 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, 3, 4 and 5 Service users and their families can expect to have sufficient information about the service and a contract for their agreed allocation of respite. Service users can expect to have their needs fully assessed prior to using the respite facility to ensure that the service meets their specific needs. EVIDENCE: The manager provided the inspector with a copy of the most recent statement of purpose and the service users guide. These are both well presented and contain a lot of very detailed information for prospective users of the service. The service user guide has been updated to include a copy of the service agreement, which was a requirement for the previous inspection in March 2005. All service users using the respite facility at Finborough Road are referred from the social services community team. The referral has details of the service user, their social worker and a brief outline for the reason the referral is being, made. Once the manager has received the referral they will visit the prospective service user in their own home to make a full admission needs assessment. The service user and the family are given copies of the statement of purpose and service user guide at the meeting and arrangements are made for trial over night respite stay. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 9 The needs assessment comprises 11 sections; personal details, medication and medical needs, mobility, communication, personal and intimate care, meals, support in the community, behaviours requiring support, personal goals, general information and specific care guidelines. Following the needs assessment the parent or carer completes a carer’s self assessment document, each question has a point scoring system between 5 and 20 points, which when completed will determine the allocation of respite available for the service user and their family. The allocations are worked out to give a fair and proportionate allocation, which includes weekends and weekdays and an agreed amount of secure and unsecured bookings. Following completion of the pre admission needs assessment a service agreement is signed by both parties setting out the terms and conditions between the service user and the service. Service users agreements seen on two care plans looked out were out of date and needed to be updated to reflect current fees being charged by the service. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 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, 8, 9 and 10 Service users can expect to have their health and personal needs identified and reviewed to ensure that their needs are met at all times. Service users can also expect to have information about them kept confidential and shared only on a need to know basis. EVIDENCE: The care plans of 2 service users were looked at; the plans were divided into 10 sections. These were well organised and contained relevant information about the service user covering a range of issues including, activities, observations, assessments, personal feedback sheets, service package, care plan of assessed needs taken form the pre admission assessment, reviews, planning documents, correspondence, administration, completed forms, legal information and restricted information. The service users care plan had detailed information on how to meet the identified support needs and any specific conditions that required additional support. They also listed the likes and dislikes and preferences of the individual, their religious, cultural or spiritual needs, health and safety considerations and any restricting factors which were identified and managed through the risk assessment process. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 11 Daily recording was very detailed and reflected the service users time during their stay. The daily recording notes are used to complete a feedback sheet for the parents or carers with details of how the service user spent their time whilst on respite at Finborough Road. They are used to evaluate how service users are included and participate in the daily routines of the service and contain information on the activities the service user has been involved in, any incidents or accidents that may have occurred, the individual skills development and progress of individual goals, health and any other relevant issues. Assessments had been undertaken to minimise identified risks with regards to manual handling, bedrails, wheelchair and personal assessments to manage continence and pressure relief. These assessments were very detailed, however they had not been updated, to show if the information was still accurate. A risk assessment had also been completed for a service user with limited mobility and communication and their ability to alert staff during the night, the manager informed the inspector that as a result when this service user is staying, one waking night staff is on duty. All other service users have risk assessments on their care plan with details of how they alert staff during the night. The service has a protocol in place for confidentiality and the sharing of information between day services and relatives. The protocol refers to information being shared and advises staff that careful thought should be given to the type of information, and that this should only be shared on a need to know basis. Communication books are used to transport information between the day services, Finborough Road and the relatives. The protocol states that staff are to use concise and professional language with no slang words, and if the information is confidential within the communication book, it must be sealed in an envelope and the persons name written on the front and clearly marked confidential. Personal information about the service user is not recorded in the communication book, unless it is specifically requested for medical reasons. Care plans are kept locked in the staff office; only staff on duty have access to this information. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 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): 11, 12, 13, 14 and 15 Service users can expect that they will be supported to take part in appropriate activities with in the local community and have the opportunity to mix with other adults. Service users can expect staff to encourage and support them to develop their social and domestic skills to enhance their independence. EVIDENCE: Each service user using the respite facility has an annual review, where their parents or carer and social worker are invited to attend. At the review the needs, aspirations and goals are discussed and agreed for the coming year. These include all aspects of the service users community, domestic and social life. These goals are agreed at the review so that the service user, their families or carers and Finborough Road are all working towards the same outcome. One service user feedback sheet seen demonstrated their progress in a range of daily living tasks; they got themselves ready for bed independently, made their own sandwich, unpacked their own suitcase and tidied their room and helped out with domestic chores such as loading and unloading the dishwasher and clearing the table after meals. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 13 Service users are encouraged to participate in the community during their stay at Finborough Road; the feedback sheets confirmed that service users had been out shopping in the town centre, they had been to the local Asda supermarket on several occasions and one service user had chosen to go to Mc Donald’s where they had enjoyed a mcflurry. They had also been to a local pub; the pub is very supportive and has got to know the staff and service users who regularly use Finborough Road Although at the time of the inspection there was only one person staying at the service, feedback sheets provided and discussion with staff gave evidence that service users choose how to spend their leisure time, watching TV or a DVD in the lounge or watching TV in their bedroom. The service user at the service on the evening of the inspection was observed to be relaxing on their bed listening to music and had a projector creating different, colourful shapes on the wall and ceiling. Staff support service users to attend local events, most recently a beer festival and a carnival. The manager informed the inspector that service users are supported to attend clubs that they belong to, during their stay, such as Gateway and a specialist club, Target. The manager has also been buying in services, such as a musician, a storyteller and a masseur. These services are paid for by the Friends of 7a Finborough Road, who are a registered charity set up to fund raise for the service. They had their 10th Anniversary on August 20th 2005 and to celebrate they organised a bar-b-que (BBQ) and an entertainer for between 50 and 60 people, which included people that had used or been involved in the service over the past 10 years. Service users are encouraged to maintain family links and friendships. A recommendation from the previous inspection was for the service to consider how service users could be offered a private space other than their bedrooms when they receive visitors. This is an unresolved issue as there are no available rooms to create a visitors room. The manager informed the inspector that visitors are mostly relatives that enjoy mixing with the other service users when they visit and service users are happy to receive their relatives in their rooms if they choose to see them privately. Due to the nature of the service and mix of service users, the home promotes opportunities for people to meet and develop relationships with other people of their choice. Individuals sexual needs are identified in the initial assessment however, this is a generic assessment and does not take into account the specific behaviours of the individual and if they are appropriate when mixing with other service users. Through discussion with the manager each service users specific sexual needs will be identified in their care plan, and have agreed the appropriate support and information and guidance to meet their own needs and support to develop relationships but also protect others against abuse. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 14 The service user staying at the service had already had a cooked lunch at the day centre and therefore only required a light snack for their evening meal. It was therefore not possible to fully assess standard 17. However, observation of the staff member assisting the service user was that they gave them plenty of time to eat their food, they appeared relaxed and to enjoy their meal. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 Service users can expect to be treated with dignity and their privacy upheld. They can also expect to have their prescribed medication administered correctly. EVIDENCE: The majority of service users that use Finborugh Road respite service are able to maintain their own personal care, with some prompting from staff. Care plans document the assistance required. Service users care plans are updated annually at the review, however, as service users use the service intermittently, the inspector asked the manager and deputy how any changes to the personal care, physical and emotional needs of the service users were identified. The manager and deputy explained that as part of the pre admission assessment staff go through a list called the “Top ten” which provides a brief overview of the service users preferences, likes and dislikes and what support they need, however, these had not been reviewed since the initial assessment. The district nurse was visiting the home on the day of the inspection, and was observed to attend to the personal intimate care needs of the service user on respite with the assistance of a member of staff in the privacy of the service user’s room. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 16 The district nurse had only visited the home on 2 occasions, but was able to comment that they had found staff to be capable and kind and pleasant, they had not experienced any problems with the home. The home has introduced protocols to guide staff in the procedures to follow for the recognition and prevention of pressure areas and the promotion and management of service users continence. The protocol for pressure care involves information of what and how pressure areas occur and staff practice to prevent them occurring. The protocol guides staff to contact the district nurse to treat any pressure sore areas identified and that any treatment is recorded in the service users care plan and monitored. The protocol for continence promotion and management guides staff to make a full assessment taking into account the factors that may trigger the service users incontinence. An action plan is then tailored to meet the individual’s needs, including an assessment from the continence advisor for products that will support the service users continence and assist them to feel comfortable and to maintain dignity and self-esteem. The inspector observed a member staff administer one service user’s teatime medication. The member of staff checked the details, name, strength and dosage on the medication administration record (MAR) chart against the box of Tegratol, they also checked the running stock total along the bottom of MAR, minus medication to be dispensed, the total was correct and matched the number of tablets remaining. The district nurse had administered an enema to the service user staying in the home. The Fletcher enema was recorded on the MAR as given by district nurse. The inspector observed the member of staff administer the medication to the service user in their room, they were supportive and respectful of the service users dignity and difficulties taking the medication, they encouraged the service user to take the medication using a spoon, and offering them a drink. MAR charts seen were designed by the manager on the computer. They had consulted with the general practitioner (GP) used by the service and pharmacy records and information taken from the needs assessment to implement the MAR charts. Service users living at home do not have medication blister packs, they therefore bring all medicines in the boxes supplied by the pharmacy. The service designed the MAR charts to keep an accurate record of medication being brought into the home and administered and returned to the family home. The member of staff administering medication informed the inspector that they were in the process of completing their nurse training, and was familiar with the process of administering medication, and administering insulin to a service user. They informed the inspector that staff had been trained by the district nurse to administer the insulin via a pen and had given them advice on the signs and symptoms of diabetes and the importance of monitoring blood sugar levels. The deputy manager confirmed that all staff had received training by the district nurse; however, they did not have a list of approved staff signed and dated by the district nurse. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 17 Finborough Road has a protocol in place for actions to be taken in the event of the death of a service user whilst on respite. The protocol instructs staff to notify the next of kin immediately, the service users GP, the manager, and the undertaker as directed in the service users care plan. The manager will make a record of the reason for the service users death and immediately notify their manager and the director of social services and the commission of social care inspection (CSCI). The service users guide details the actions the service will take if a service user becomes ill whilst staying at Finborough Road. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The service has a clear policy and procedure in place for dealing with complaints and service users can expect to be supported to make a complaint, however, service users cannot expect to be protected from abuse or neglect until all staff have received the appropriate training. EVIDENCE: The complaints procedure was included in the service user guide and statement of purpose, both had very detailed information about the complaints process. The service has leaflets available from Suffolk County Council called “having your say” which are available in written or a service user-friendly format with pictures. A copy of one of the leaflets was pinned to the notice board in the hallway. Both the statement of purpose and service user guide confirmed that service users had a right to complain directly to the commission for social care inspection (CSCI) and had the address and contact number. There have been no complaints since the previous inspection in March 2005. Training records show that the manager and one other member of staff have attended vulnerable adults training in March 2005, the acting manager had had training in March 2004, three staff had had training in June 2003, one staff had training in 2001 and another member of staff had no training at all. The manager informed the inspector that they were devising a training package to become part of the personal development plan for all staff and that they would be delivering a refresher course, however no date has been arranged. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 19 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, 26, 27, 28, 29 and 30 Service users can expect to live in a safe, well-maintained and welcoming environment, which provides a good range of communal and personal accommodation, although they cannot expect to have a separate private room to receive visitors. Service users can expect that the service will be kept clean and hygienic and have access to aids and equipment they need to promote maximum comfort and independence. EVIDENCE: Finborough Road provides a homely and domestic environment. The home has four bedrooms; two rooms on the ground floor were seen. The bedrooms were nicely decorated, providing the basic furniture and equipment needed for the service users stay. All the bedrooms have a television and one room had a computer. Only one room was occupied on the day of the inspection and although it was difficult to personalise the room due to service user only staying for a short period, the inspector observed that the staff had arranged the service users’ belongings to make the room feel homely and personal. All bedrooms have a lock and service users are offered a key to their room during their stay. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 20 Other rooms consist of a large entrance hallway, a large kitchen and dining room that has double doors that open out onto a patio area and a lounge. An internal pipe leak had caused considerable damage to the hall and lounge walls. The leak has now been repaired, the walls had needed to be re-plastered and decorated. The hall and lounge had been papered and the woodwork paint in the lounge had been completed on the day of the inspection, so there were no curtains in place at the window, new curtains have been purchased to match new furniture of two leather sofas and two recliner chairs. The overall effect gave a pleasant, comfortable and welcoming area for service users to relax. The service has a shower room with a toilet on the ground floor, which is accessible for wheelchair users; there is also a separate toilet along the corridor. On the first floor there is another bathroom with a shower and toilet, and another separate toilet. There is a laundry room on the ground floor, which has a washing machine with a sluice facility that has a urine neutraliser containing a chlorine-releasing agent. All soiled linen is placed in water-soluble bags and put on to the sluice wash and then washed at the highest temperature setting. All cleaning products were locked away in cupboards out of reach from service users. The service user staying at the home had brought with them their own wheelchair and especially adapted armchair. Finborough Road has a selection of specialist aids and equipment. They had provided the hoist in the service user’s room and a bed that raises and lowers in height and has adjustable head and feet raisers to provide maximum comfort for the service user. The bed had bedsides which had been risk assessed for the individual. The service also has a shower commode and shower bed available for use. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 21 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): 31, 32, 33, 34, 35 and 36 Service users can expect to be supported by a staff team, who are supervised, supported and available in sufficient numbers to meet their needs, however they cannot expect to be protected by a staff team who have the appropriate recruitment checks in place or current training in the protection of vulnerable adults. EVIDENCE: The staff rota was seen. The service aims to have 2 staff on the morning shift between 7am to 9.45am, and then 2 staff for the afternoon and evening shift between 3.30pm to 10pm with 1 member of staff sleeping in. There is only 1 service user that needs night support and on these nights a waking night staff is on duty, but no sleeping in staff. On a Monday morning 3 staff work the early hours to help ‘book out’ the weekend service users. The rota reflected the staff numbers, however, there were additional staff hours on the rota for a member of staff to visit a service user living at the family home for two hours care a day. The manager explained this was to build up a trust and confidence for the family to use the respite service in the future. Finborough Road also allocates one member of staff to visit a service user living in their own home for one hour a week to check that they were taking their medication correctly, although the manager confirmed that this would be ending soon. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 22 Whilst these care hours do not detract from the service at Finborough Road this information was not referred to as a service in the statement of purpose or service users guide. Three staff files were looked at and each had a job description, job application with photo for identity attached and a history of their working carer, all had a criminal records bureau (CRB) check and a Suffolk county council criminal record check of a potential employee. One staff file did not have the copy of the enhanced CRB on their file. The acting manager told the inspector it had been destroyed as it had been seen by the previous inspector, however, there was no record kept of the details of the CRB, the other two staff still had their CRB’s in their files. A previous requirement from the last inspection in March 2005, raised concerns that the clerical worker and domestic had no CRB the manager had assured the inspector that the reason for this was that these employees had no contact with the service users as there hours were worked whilst service users were at respite, however, the clerical worker was present on the day of the inspection whilst a service user was at the service. The manager agreed that a CRB would be undertaken for this employee. The manager informed the inspector that the domestic was retiring in December and assured them that the replacement domestic would have a CRB. Each staff file had evidence that they were receiving regular supervision and an annual performance and development appraisal and regular training. Training records and staff files seen showed that all staff had re credited training with Unisafe in February and September 2005, Food Hygiene refreshers in December 2004 and epilepsy awareness training in April 2005; however, staff had not had recent refresher training in adult protection, administration of medication or complaints and compliments. The staff training record seen did not accurately reflect the training within the service. According to the record no staff had had manual handling refresher training with the exception of one member of staff who had had training in July 2005, however the staff files seen indicated that staff had had recent training. The manager and acting manager held national vocational qualifications (NVQ) level 4, obtained in August 2004. Staff files showed that other staff also held an NVQ certificate level 3. The most recent member of staff, who commenced employment in October 2004, had completed the sector skills council for social care (TOPPS) induction and foundation at the south Suffolk professional development centre between December 2004 and March 2005. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 23 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, 41 and 43 Service users can expect to stay in a service that is run in their best interests by an experienced management and staff team, and can expect to be protected by the homes policies and procedures. EVIDENCE: The registered manager has been seconded to manage the nearby St Edmunds service and the deputy manager is currently managing Finborough Road. Both managers were at Finborough Road on the day of the inspection. The agreement between the social care manager and the commission for social care inspection (CSCI) for this secondment is due to end in September 2005. The responsible individual has been in discussion with the manager and deputy regarding the future management of both establishments and will be contacting the commission for social care inspection (CSCI) requesting an extension to the agreement. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 24 The manager and deputy manager both have obtained level 4 National Vocational Qualifications (NVQ) and have the skills and experience of working in a care setting. Staff spoken with confirmed that both the manager and deputy were approachable and worked well together for the benefit of the service. Staff informed the inspector that they enjoyed working at Finbourough Road. The service has a nice atmosphere and that they enjoyed working with service users who are all different personalities and characters. The manager of 7a also manages the domiciliary service 7b next door. Staff told the inspector that staff meetings are held on a regular basis, every two weeks; these are held in separate rooms to discuss issues about each particular service, however the staff from both services join together to discuss training issues, most recently to practice the unisafe de-escalation techniques and makaton. Finborough Road provides two bedrooms and bathroom facilities on the ground floor for service users with a physical disability in addition to their learning disabilities. The manager said they are discussing the possibility of introducing new and future service users to Finborough Road by providing further outreach services and a possible mini break service. The financial viability of the service was discussed and the manager informed the inspector that the service operates with 80 to 85 percent occupancy throughout the year and that it was rare to have a situation where there is only 1 service user staying. The normal procedure is that the manager will ring users of the service if there are vacancies available. In April 2005 the deputy manager of the service produced and updated a range of protocols advising staff of procedures to follow in the event of out of hours contacts, dealing with emergencies and police involvement, missing persons, dress code, death of a service user, pressure relief, continence promotion, confidentiality, use of e-mails, keys and key holders and right of access to the service, accidents, petty cash and personal money, food safety, using telephones and disclosure of offences since commencement of employment. These protocols are well written and contain a lot of detailed and factual information and are made available to all staff for guidance of their responsibilities whilst working within the service. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 x 3 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 2 16 x 17 Standard No 31 32 33 34 35 36 Score 3 2 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 7a Finborough Road Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 x x 3 x 3 DS0000036836.V250681.R01.S.doc Version 5.0 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA5 Regulation 5 (b) Requirement The terms and conditions in respect of accommodation to be provided to the service user must be updated to include the current fee and method of payment. Risk assessments undertaken to identify risks to the health and welfare of service users must be reviewed to ensure that any changes in the service users needs are identified and unnecessary risks relating to such changes are eliminated. Where the service provides opportunities for service users to meet and develop relationships their sexual needs will be identified in their care plan, and have agreed the appropriate support and information and guidance to meet their own needs and support to develop relationships but also protect others against abuse. Timescale for action 07/11/07 2 YA9 13 (4) (b) (c) 07/11/05 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 27 3 YA23 13 (b) 4 YA34 Sch 2 (7) All staff must receive training in protection of vulnerable adults to prevent service users being harmed or suffering from abuse or being placed at risk of harm or abuse All persons working at the home must have a CRB issued, which includes the clerical and domestic staff and a record kept on their file of the details of the CRB, if the original is destroyed. 05/12/05 19/09/05 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 YA35 Good Practice Recommendations The service should have a training and development plan that is kept up to date and reflects current training and a training needs assessment for the whole staff team and their development and benefit the service users. 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 7a Finborough Road DS0000036836.V250681.R01.S.doc Version 5.0 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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