Inspection on 08/03/07 for 93 Ings Road

This inspection was carried out on 8th 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 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

93 Ings Road 25/07/06

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 93 Ings Road Clarence house 62 Clarence Street Hull HU9 1DN Lead Inspector Beverly Hill Key Unannounced Inspection 8th March 2007 09:30 DS0000065523.V332524.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 DS0000065523.V332524.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. DS0000065523.V332524.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 93 Ings Road Address Clarence house 62 Clarence Street Hull HU9 1DN 01482 329226 01482 329337 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) Avocet Trust Position Vacant Care Home 5 Category(ies) of Learning disability (5) registration, with number of places DS0000065523.V332524.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th Oct 2006 Brief Description of the Service: The service at 93 Ings Rd is managed by Avocet Trust. It is one of a small number of similar services that Avocet provides. Avocet Trust is a registered charity. This service was a new registration in 2005. 93 Ings rd is a detached house registered to provide respite care for up to five service users. The home is situated on Ings Rd to the east of the city of Hull. The house consists of a hall, lounge, dining room, kitchen, small utility room, two bathrooms one upstairs and one downstairs and five single bedrooms all but one of these being upstairs. One of the upstairs bedrooms has an en-suite shower room. The house has a private garden to the rear of the property and space for two cars at the front. There are a variety of shops, pubs, GP surgeries and post office all within walking distance. Public transport to various parts of the city is easily accessible. Weekly fees range from £840 - £2578.94 per person per week. Additional charges are made for the following: newspapers/magazines, hairdressing, chiropody, transport for social activities and sweets. Information on the service is made available to current service users via the statement of purpose, service user guide and inspection report. DS0000065523.V332524.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit to the home was carried out over one day. Throughout the day the inspector spoke to staff members to gain a picture of what life was like for people who have short stays at 93 Ings Road. The inspector telephoned two relatives and received a survey back from a third relative. The service users that stay at the respite service have complicated needs and are not able to tell the inspector of their views therefore in this report comments from relatives, professional visitors and staff have been used to help to form a view about whether service users needs are met or not. The inspector also had discussions with the manager and service director. The inspector looked at assessments of need made before people were admitted to the home, and the home’s care plans to see how those needs were met while they were staying there. Also examined were medication practices, activities provided, nutrition, complaints management, staffing levels, staff training, induction and supervision, how the home monitored the quality of the service it provided and how the home was managed overall. The inspector observed the way staff spoke to service users and supported them, and checked out with them their understanding of how to maintain privacy, dignity and choice. The inspector also checked that people were supported and protected in a safe and clean environment. What the service does well: There has been no change in what the service does well. Avocet Trust continues to provide accommodation and personal care support and is a good service for adults with a learning disability and other needs. The primary aim is to enable people to develop and maintain as much independence as possible, whilst helping them to be more confident and access community facilities. Service users and their relatives are given enough information about the home to enable than to make a choice about whether it will be suitable for them or not. The house is located in the local community and is on a bus route making all leisure facilities and shops easy to get to. All service users are provided with a single room that meets their needs, in a house for no more than five people thereby providing them with a home and private areas to their liking where they can spend private time or receive visitors. DS0000065523.V332524.R01.S.doc Version 5.2 Page 6 Families are encouraged to be involved as much as they wish to and are made to feel welcome when visiting their relative. Service users are able to continue with all of their planned activities and are supported by the staff team to do so whilst staying at the home. Service users receive a healthy diet and their likes and dislikes are also taken into account. The home is clean and tidy with a ramp access for wheelchair users. What has improved since the last inspection? What they could do better: One person who had been staying at the home for some time did not have all the care they required written down in a plan. This had been started but staff did not have full guidance on how to support the person. Care plans must be completed quickly to ensure that staff members knew exactly how to support DS0000065523.V332524.R01.S.doc Version 5.2 Page 7 someone or care could be missed. This also applies to plans informing staff how to manage behaviours that cause difficulties and health issues. The manager must ensure that the documentation supporting medication is improved so that all medication is recorded when received into the home and when given to people. When not given to people this must be recorded by using the codes consistently and when writing information about medication onto the record sheet this must be accurate. Good recording is important to ensure staff know what medication people have had and the reasons why if it is not given. The home is allowed to employ staff whilst awaiting the return of the criminal record bureau check in exceptional circumstances and only when all other checks have been done. When this happens the home must make sure that the staff member has stringent supervision arrangements in place and CSCI are aware of the action. Each member of staff at the home should have a regular meeting with the manager to discuss the training they may need, support and other things. This has not been happening as often as it should. Although improvements have been made to the training staff receive, some mandatory training needs updating and staff don’t have access to courses that would develop them further, for example in conditions that affect service users and personal development. The system for monitoring the quality of the service has been started but information from self-assessment and questionnaires needs to be collated, checked and evaluated so that improvements can be made in some areas. 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. DS0000065523.V332524.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 DS0000065523.V332524.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 good. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed prior to admission which means the home is able to determine whether they are able to meet needs. EVIDENCE: The manager confirmed that service users needs were assessed prior to admission to the home and assessments completed by care management were obtained. Two files were examined in detail and another perused for assessment information. Documentation confirmed that service users were only admitted to the home when their needs have been assessed. This information was crucial in the decision making process as to whether the home was able to meet peoples’ needs and used when formulating plans of care. The manager needs to routinely write to service users or their representatives following the pre-admission assessment formally stating their ability to meet identified needs. This correspondence needs to be maintained on file. DS0000065523.V332524.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): 6, 7 and 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. On the whole service users had their needs met and these were detailed in individual plans of care, which were reviewed at intervals. One service user did not have a comprehensive behaviour management plan, which could place them and staff members at risk. EVIDENCE: Two care files were examined in detail and one showed a marked improvement in the care plan from the last key inspection. The other was a care plan formulated for a new service user and had not been fully completed. The care files had lots of information regarding the needs of the service users, including risk assessments, moving and handling assessments, epilepsy management and treatment plans, and various monitoring charts for behaviour, bowel care, sleep patterns and nutritional intake. DS0000065523.V332524.R01.S.doc Version 5.2 Page 11 The individual care plan consisted of IPPs (individual programme plans) and management plans. The improved care plan incorporated the service users strengths and needs and indicated how staff members were to support the person to maintain privacy, dignity and choice throughout a range of activities from personal care to community participation. The management plans were added information for particular tasks and the manager confirmed these were usually put in place when some element of risk has been identified. However some of the management plans covered basic information such as personal care tasks, which could be incorporated into the IPP to save duplication of documentation. One of the care files had not been completed fully and the inspector was unsure that care staff would have full guidance and information in order to meet the service users needs. For example areas such as personal care, nutrition, behaviour management and activities had not been completed. The service user had been known to the service for two months. The manager stated staff were still collating information about the service users needs in order to formulate a thorough care plan and some staff spoken to were aware of the service users basic needs as these had been passed on verbally. Care plans must be formulated as soon as possible to give staff clear guidance regarding the tasks they need to complete to meet needs. Without this there is a risk of care being missed and behaviour not being managed appropriately. Care plans can always be updated as more information is discovered. One person needed to have bowel care medication and other medication administered in a particular priority order as they sometimes declined medication after a certain point. A visiting professional had completed the service users health action plan, although the manager confirmed that the priority of order of medication had been accidentally omitted. The health action plan also stated the service user was to have caffeine free drinks but when spoken to staff were not aware of this. Protocols for the administration of the bowel care medication were not in place. These issues must be addressed quickly and staff made aware. There was evidence that reviews had been held with relatives and professionals present. DS0000065523.V332524.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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A wide range of activities within the home and community means that service users continue to have the opportunity to participate in stimulating and motivating activities that meet their individual needs, wants and aspirations. EVIDENCE: There was evidence on care files examined that service users continue with their planned activities whilst staying at the home for respite care. On the day of the site visit one service user was out in the community and another was visiting family. Service users care files examined contained an activity timetable, although one still required some attention. Staff discussions also confirmed a range of activities including shopping, visits to the pub, snooker, visits to the adult education centre, horse riding, bowling, swimming, use of computers, visits to the local park and Humber Bridge country park, local community centres, days DS0000065523.V332524.R01.S.doc Version 5.2 Page 13 out to Hornsea and Bridlington, watching videos and TV and listening to music at home. Some people like to cook and bake and one service user enjoys bringing in a musical instrument. Service users are able to access Avocets own day service whilst receiving respite care. The house is situated in the local community and blends in well with its surroundings. All service users have an individual bedroom where they can spend private time and they have unrestricted access to all areas of the house. Bedrooms have privacy locks and lockable facilities for personal items. The home has good links with families and they are made welcome at the home and are able to visit whenever they wish, however the very nature of the service (respite care) means that they do not take up this offer very often as they are taking a well-earned break. However one relative commented that they would like to have more contact with their relative when in respite and would appreciate staff supporting them to telephone them. Another mentioned that when they telephone the home they are only given very basic information about fluid intake and they would like a much fuller picture of the days’ activities. This was mentioned to the manager to address. The manager and staff promote a healthy eating menu but try to balance this with service users likes/dislikes and special treats on occasions. Care files contained information on likes, dislikes and preferences. The menu plan is presented in a pictorial format for service users. The choice of meals has not changed since the last inspection. Breakfast consists of a variety of cereals, toast, tea, coffee and juice. Lunch is a choice of sandwiches, soup, beans or egg on toast, omelette or jacket potatoes with a choice of fillings. Options on the menu for dinner included chicken, mince, pasta, fish, all served with fresh vegetables and the manager confirmed that there is always plenty of fresh fruit and yogurts available. Staff stated that some service users enjoyed shopping for food at local supermarkets. Staff confirmed that currently there was no service user on a specialist diet although one person had fortified drinks. This was confirmed in care plan documentation. DS0000065523.V332524.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 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally the health and personal care needs of service users were met. However shortfalls in the monitoring of some health needs and omissions from the health action plan of one service user could mean that not all their needs will be met consistently. EVIDENCE: The nature of the service (respite care) means that relatives managed the majority of the service users health needs when they are living at home, but care staff will support service users to attend any appointments whilst staying at the home. Daily records were maintained and there was evidence that a range of professionals continued to support service users with their health care needs whilst in respite care. One relative stated that they had requested fluid monitoring charts to be completed for their relative whilst they are in respite but this is not always adequately done. A result of inadequate fluid intake had in the past resulted in urinary infections and the relative wanted reassurance DS0000065523.V332524.R01.S.doc Version 5.2 Page 15 that the home monitored this. This was mentioned to the manager to check out. One of the service users staying at the home on the day of inspection has particular health needs and has the ongoing support of the community nurse and epilepsy nurse. An epilepsy management and treatment plan was in place that staff members understood and followed. A health action plan had been formulated although one area, for example the priority order of medication administration, which was present in an earlier plan had been omitted and bowel management was not fully addressed. The manager was aware of these issues and was to contact the community nurse to discuss. Some areas of the plan were unknown to staff, for example the health action plan stated the service user was to have decaffeinated drinks but this was not applied in practice. Some monitoring charts, for example behaviour monitoring, bowel and nutrition had not been completed consistently, which would only give limited information to staff. Service users weights were not always obtained. The management of medication was assessed as part of this inspection and the inspector discussed the systems with staff members and examined the stocks of medication and recording tools. The inspector was informed that service users bring in their stock of medication with them on admission. The medication is entered onto the stock control sheet and then transcribed by staff onto the medication administration sheets. On examination of documentation there continued to be mistakes made in transcribing, for example paracetamol medication must have the full manufacturers instructions transcribed onto the MAR. When medication was not given codes were not used consistently, and there were one or two missed signatures. There was a stock of eye drops for one service user held, however there was no record on the MAR sheet for administration. The registered person must ensure that medication documentation is improved and all medication received into the home must be entered onto the MAR. Since the last inspection medication that must be stored in the fridge was held in a secured container. Not all staff have completed a medication training course that includes a competency check and this must be addressed. The manager confirmed staff members were booked onto a training course. DS0000065523.V332524.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements in care planning and staff training means that service users are protected from harm whilst in the home. Staff awareness of the complaints process means that any issues are dealt with quickly before escalating into major complaints. EVIDENCE: Neither the home nor the CSCI had received any formal complaints about the home since the last inspection. The home had a complaints procedure that was displayed in the home. Staff members were aware of the procedure and the documentation used to record complaints. One relative commented they were unsure about the homes complaint procedure. The home had policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of service users money and financial affairs. The manager and all staff have received training in the protection of vulnerable adults from abuse and most had completed training in how to manage challenging behaviours. The staff on duty displayed a good understanding of the vulnerable adults procedure and they are confident about reporting any concerns and certain that any allegations would be followed up promptly, and the correct action to be taken. DS0000065523.V332524.R01.S.doc Version 5.2 Page 17 DS0000065523.V332524.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, 25, 26 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home continues to provide a safe, clean and comfortable environment for service users. EVIDENCE: 93 Ings Rd is a semi-detached house registered to provide respite care for up to five service users. The home is situated on Ings Rd to the east of the city of Hull. The house consisted of a hall, lounge, dining room, which doubled as a sleep in room for staff, kitchen with a table and chairs, small utility area, two bathrooms one upstairs and one downstairs and five single bedrooms all bar one upstairs. One of the upstairs bedrooms has an en-suite shower room. The manager confirmed that at the last inspection the dining room was also used as an office. However this limited space for service users and there are now plans to convert part of one of the bedrooms into office space. DS0000065523.V332524.R01.S.doc Version 5.2 Page 19 Occupied bedrooms were personalised to varying degrees. As the home was for respite care service users did not bring large amounts of personal items into the home. All bedroom doors had privacy locks and lockable facilities were provided. The house has a private garden to the rear of the property and space for two cars at the front. There was a ramp to the patio doors at the side of the house for wheelchair users. On the day of inspection the house was found to be clean, tidy and provided a homely and comfortable environment for service users to stay in. The house is just large enough to accommodate five service users and provides plenty of communal space. All the required equipment was in place to meet service users needs. DS0000065523.V332524.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, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made in staff deployment, induction and training, however shortfalls in staff supervision and one area of recruitment could place service users at risk. EVIDENCE: There are currently eight service users that regularly use the service at 93 Ings Rd for respite care, although the home accommodates a maximum of five people at any one time. Relatives spoken to were happy with the numbers of staff on duty and stated they were spoken to in a professional way. Staff surveys received and a staff member spoken to on the day indicated that they enjoyed their work and felt that there had been improvements in staffing arrangements. Morale was described as high and staff felt supported by the manager. The manager confirmed that service users were now receiving rolling respite in a structured way and this enabled them to plan more effectively. The home DS0000065523.V332524.R01.S.doc Version 5.2 Page 21 had a core staff team of seven and access to four bank staff when service users required extra funded support. Senior managers had reviewed the grades of staff working at the home and ensured that staff members had the opportunity to complete induction and mandatory training to enable them to increase their grade and skills. Not all staff members have received the General Social Care Council code of conduct and information was left with the manager regarding obtaining the code for staff to read and adhere to. The company’s headquarters formulated the training plan and the one seen by the inspector ran up until 31st March 2006. The manager confirmed that a new training plan would be underway but the home had not received it yet. Individual training records were maintained and forwarded to HQ for planning. This enabled training requirements to be tracked and mandatory updates recorded and addressed. The training plan observed did tend to focus on mandatory training with limited scope for expansion to cover specific health conditions that affect service users or other development opportunities for staff. Individual training records were examined and evidenced that mandatory training had been undertaken or was booked for new staff members. Some updates were required for existing staff but these had been planned in most cases. Two staff members had completed a non-verbal communication course, Makaton, and a further two staff were due to start in April. Five of the seven, core staff team had completed NVQ to level 2 or 3 which was a good achievement. The inspector was unable to see training records for bank staff. These workers tended to work in other areas of the company and the manager confirmed training records were maintained there. The inspector advised that copies of training records for staff employed in the home needs to be accessible during inspections. Since the last inspection all staff had completed training in how to deal with behaviours that may be difficult to manage and all new staff had started appropriate induction (LDAF). The manager stated there had been some difficulty in obtaining mentors for the induction course but this had now been resolved. Avocet Trust has plans to reorganise induction into an initial twoweek period to enable LDAF to be completed during this time. The company’s recruitment process was generally robust. Application forms were completed and references and police checks obtained. Potential applicants were selected via a solid interview process. However in one file examined the staff member started employment after a satisfactory povafirst check but prior to the return of the criminal record bureau check. This is acceptable only in exceptional circumstances and the home must evidence that stringent supervision arrangements are in place until the final check is received. The inspector could not find evidence of this level of stringent DS0000065523.V332524.R01.S.doc Version 5.2 Page 22 supervision. The company must address this issue to ensure service users are protected. Not all staff had received formal 1-1 supervision or appraisals. This was important for the protection of service users and the development of staff. All staff must receive at least six supervision sessions per year to meet requirements. This was an outstanding requirement from the last inspection and must be addressed. . DS0000065523.V332524.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally the home was well managed and improvements have been made in management hours. Full implementation of the homes quality assurance system and greater service user consultation will promote good practice and improve further the health, safety and welfare of service users and staff. EVIDENCE: The manager has recently applied to the Commission to be registered and this process is currently underway. He has a variety of skills, relevant qualifications and experience and has managed care homes in the past. The managers’ hours had been reviewed and from 1.4.07 they would work nineteen hours of shift work each week leaving eighteen hours for the management of Ings Road and Avocet Domiciliary Care Services. The manager DS0000065523.V332524.R01.S.doc Version 5.2 Page 24 confirmed this would enable them to concentrate on management tasks such as quality assurance, planning and staff supervision. As part of the inspection all health and safety, and the maintenance certificates were examined, all were available and up to date. A systematic approach to quality assurance has been developed and relatives spoken to confirmed they had received questionnaires about the running of the respite service. There was a system for the respite service to self-assess with scores and be assessed by a review team with analysis of the results. There was also scope for questionnaires to professionals and adapted ones for service users. The information needs to be collated and evaluated and action plans produced to address any shortfalls. This latter part of the process has not been implemented yet. Consultation with service users could be improved although staff stated they tended to speak to people on a daily basis when they were in respite to ensure they made decisions about their lives. Smaller group discussions about service provision could be documented to evidence decisionmaking. The inspector saw a letter received from a professional praising the partnership between the staff at Ings road and the health team for a specific service user. The trustees of Avocet Trust undertake regulation 26 visits, the manager holds staff meetings and management meetings take place monthly. DS0000065523.V332524.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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 3 X DS0000065523.V332524.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15 Requirement The registered person must ensure that all service users have an individual plan that covers all aspects of personal, social and health needs. (Timescale of 31/10/06 not met) The registered person must ensure that where service users display behaviours that are likely to cause harm to themselves and/or others, that a behaviour management plan is put in place that all staff understand and follow. (Timescale of 30/09/06 not met) The registered person must ensure that the health action plan of one service user is amended to include all relevant information and monitoring charts are completed consistently. The registered person must ensure that all staff responsible for administering medication have received training and have their competency assessed. (Timescale of 31/12/06 not met) DS0000065523.V332524.R01.S.doc Timescale for action 30/04/07 2. YA7 13 (6) 30/04/07 3. YA19 15 30/04/07 4. YA20 18 31/05/07 Version 5.2 Page 27 5. YA20 13(2) 6. YA34 19 7. YA35 18 8. YA35 18 9. YA36 18 10. YA39 24 The registered person must ensure that medications are recorded appropriately and instructions are transcribed accurately. The registered person must ensure that stringent supervision arrangements are in place in the exceptional circumstance that a staff member is employed after the povafirst check but prior to the return of the criminal record bureau check. CSCI must also be advised when this occurs. The registered person must ensure that all staff are up to date with their mandatory training. (Timescale of 31/08/06 not met) The registered person must ensure that the training plan is expanded so staff members have the opportunity to participate in other training and in the conditions affecting service users with a learning difficulty. This will further develop their skills, knowledge and personal development. The registered person must ensure that all staff are on track to receive formal supervision at least 6 times per year. (Timescale of 31/12/06 not met) The registered person must ensure that the quality assurance system is implemented fully to improve consultation about how the service is provided. 30/04/07 13/04/07 30/06/07 30/06/07 30/06/07 31/05/07 DS0000065523.V332524.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard YA6 YA15 YA15 YA34 YA37 Good Practice Recommendations The manager should review the structure of care files to avoid duplication and ensure management plans for basic care support are included in the IPP. The manager should take steps to improve communication between staff and relatives and so relieve anxieties regarding service users activities whilst in the home. The manager should support a particular service user to increase contact with a specific family member during their stay. The manager should obtain the General Social Care Council code of conduct for staff and ensure they read and adhere to it. The manager should continue the process of registration with CSCI and investigate whether their current qualifications meet the requirements of NVQ level 4 in care and management. DS0000065523.V332524.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000065523.V332524.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. 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