Inspection on 13/06/08 for Allan House

This inspection was carried out on 13th June 2008.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Allan House 09/11/09

Allan House 21/07/09

Allan House 02/10/06

Allan House 12/11/05

Allan House 13/06/05

Allan House 01/11/04

Allan House 18/05/04

Allan House 29/07/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Allan House 53 Uttoxeter Road Blythe Bridge Stoke On Trent Staffordshire ST11 9JG Lead Inspector Sue Woods and Rebecca Harrison Unannounced Inspection 13th June 2008 10:00 Allan House DS0000004906.V366049.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 Allan House DS0000004906.V366049.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. Allan House DS0000004906.V366049.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Allan House Address 53 Uttoxeter Road Blythe Bridge Stoke On Trent Staffordshire ST11 9JG 01782 397018 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) allan@jeffriesgroup.com Mrs Grace Jeffries Mr Ronald Jeffries Alison Nicklin Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Allan House DS0000004906.V366049.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd October 2006 Brief Description of the Service: Allan House is an eight-bedded care home for people who have a learning disability. The home is one of two homes owned by Mrs Jeffries and her son. The home is located on the main road in Blythe Bridge and blends in with the surrounding properties. The home is a two-storey large family type house although all bedrooms and lounges are on the ground floor. The home provides six single bedrooms and one double bedroom. The environment internally is of a good standard and outside at the front is a car park and at the rear a large garden. The people who live at Allan House access local health resources and seven people attend college, day centres or day services. The service users generally have low to moderate needs although the home is able to respond to some challenging behaviour. The aim of the home is to promote and develop the independence skills of the service users and if appropriate to support them to move to more independent living environment. Information is shared with people who live at the home during regular house meetings. Everyone is invited to attend. A quality assurance system is in place in the form of questionnaires that form the basis of an improvement plan developed by the manager. Because a Service User Guide is not available, we are not able to confirm the present fees charged by the Home, therefore the reader may wish to contact the Home directly for more information. Allan House DS0000004906.V366049.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use this service experience adequate quality outcomes. The unannounced key inspection of Allan House took place on 13th June 2008 at 10.00 am. Two inspectors carried out the inspection that lasted four and a half hours. The inspection reviewed all twenty two of the key standards for care homes for younger adults and information to produce this report was gathered from the findings on the day and also by review of information received by CSCI prior to the inspection date. A quality rating based on each outcome area for service users has been identified. These ratings are described as excellent/good/adequate or poor based on findings of the inspection activity. As part of the inspection we, the commission, spoke with people who live at the home over the telephone or in person at the time of the inspection and spoke with a staff member on duty. We also received written responses to surveys sent out prior to the inspection from five people living at the home and one staff member. Support for the inspection came from the registered manager who was fully supportive of the process. We reviewed in detail two care files, two staff files and other records, policies and documents referred to within the report. Prior to the inspection visit the registered manager completed and returned an Annual Quality Assurance Assessment (AQAA) and a copy was given to the inspectors on the day of the inspection visit. The AQAA accurately and openly reflected the service offered by the home. What the service does well: People who live at Allan House told us that they enjoy living at the home; they like the staff and lead an active lifestyle. People have opportunities to say how they feel about all aspects of the running of the home and records reflect that suggestions are acted upon. Everyone who completed a survey said that staff ‘always’ treat them well and listen to what they say. Staff have a good understanding of the needs of the people they support and have developed good working relationships with service users, their relatives and other agencies. Allan House DS0000004906.V366049.R01.S.doc Version 5.2 Page 6 One staff member commented that Allan House ‘Provides a good home and support & clients are happy where they live, they are protected and well looked after’. The manager thinks that the home provides good ‘opportunities for people to take part in activities outside of the home such as clubs and discos and regularly use local amenities. People living at the home also felt that they are involved in ‘plenty of activities’ What has improved since the last inspection? What they could do better: Two requirements were made as a result of this inspection. One requirement related to the need to develop and implement a Service User Guide in order to ensure people interested in living at the home (and people already there) have access to information about the service offered. The second requirement relates to the need for the home to review and update its policies, procedures and practices in relation to safeguarding people from abuse. Following the inspection the manager of the home identified that this process has already started. One suggestion for improvement made by us, and supported by the manager, was to make support plans more detailed and describe how individual’s needs in respect of their health and welfare are to be met. This will help staff to provide support in such a way as to ensure all service users needs are met. Other suggestions included the need to improve support and induction for staff Allan House DS0000004906.V366049.R01.S.doc Version 5.2 Page 7 and look at the possibility of modernising the environment to reflect the age, preferences and lifestyles of the people who live there. The manager has identified a number of these areas for improvement in the self-assessment document that she completed prior to the inspection. 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. Allan House DS0000004906.V366049.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 Allan House DS0000004906.V366049.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): Standards 1 and 2 Quality in this outcome area is adequate Prospective people looking for a residential service are not provided with all of the necessary information to help them make an informed decision about whether Allan House will meet their needs. The service has assessment and admission processes in place to enable the successful admission to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Statement of Purpose in place however this requires updating to reflect current management arrangements. There have been no new admissions to the home since the last inspection however assessment procedures were considered satisfactory at previous inspections and are included in the Statement of Purpose. One person has recently left the home as it was considered the service was unable to meet the individual’s needs due to behaviours that challenged the service and the level of risk posed to other people living at the home. Allan House DS0000004906.V366049.R01.S.doc Version 5.2 Page 10 People who live at the home are made aware of what is included in the cost of living at the home and what is not. At the time of the last inspection carried out by us a requirement was made that the home develop and implement a Service User Guide. Although the home has produced a ‘brochure’ it does not contain all information that would be required in the Guide. The manager was made aware of the required content of the Service User Guide and she committed to develop one. Allan House DS0000004906.V366049.R01.S.doc Version 5.2 Page 11 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): Standards 6,7 and 9 Quality in this outcome area is adequate Support plans need further development to ensure they provide staff with detailed information to meet people’s individual needs and achieve their personal goals. People living at Allan House are supported to make decisions and enabled to take responsible risks to lead an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at all records held on behalf of two people living at Allan House. Support plans were available on both files examined and include basic information to deliver support but are not used as a working document or developed using a person centred approach. The manager fully acknowledged this and reported that a person centred plan for one individual wishing to move on is currently being developed by Social Services. The self-assessment completed by the manager states ‘We recognise that we could improve the format of our care plans by making them more user friendly’. Allan House DS0000004906.V366049.R01.S.doc Version 5.2 Page 12 She stated that she is due to attend training in person centred planning very shortly and will then implement the process with all other people living at the home. This will help identify current and changing needs of individuals in addition to their aspirations and goals. Guidelines to support identified behaviours were available and daily records maintained. The manager was advised records should be further developed to include incident sheets to help monitor and evaluate behaviours that can challenge. Minutes of a formal review held for one individual were available and evidenced that the person and significant others attended. The manager confirmed that all agreed actions had been completed. The manager reported that a review had been held but had yet to receive the minutes for the other person we looked at. It was stated that not everybody had been formally reviewed by his or her placing authority but that this was being addressed. People we spoke with told us that they attend their meetings and have access to their care files. The self-assessment completed by the manager states ‘Regular reviews take place to discuss any changing needs in healthcare or educational and occupation. Input from advocacy services is offered’. Observations made during the inspection indicate that people are able to make decisions for example the person who was present throughout the inspection was offered a choice of activities and refreshments. People told us that they have residents meetings to discuss things important to them such as activities, holidays, outings, meals and their home. The manager is looking to introduce ‘named’ workers although insisted that the team share responsibility for all individuals living at the home and represent their best interests. It was reported that one person currently has an advocate and information about such services was seen displayed in the reception area of the home. Assessments to support people with taking responsible risks were available on both files examined with evidence of review. These covered accessing the community, activities, daily living tasks and health and safety issues. A member of staff spoken with said that all staff have received training in risk assessment. Allan House DS0000004906.V366049.R01.S.doc Version 5.2 Page 13 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): Standards 12,13,15,16 and 17 Quality in this outcome area is good People living at Allan House are provided with opportunities to develop and maintain their social, educational and recreational interests and are enabled to keep in contact with family and friends. People receive a healthy, varied diet according to their dietary requirements and choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: When we arrived at the home five people were out at college or attending day services. One person went to college shortly after speaking with us and told us that she goes to college four days a week. She said ‘I love going to college I’m doing a Skills for Work course and would like to get a job soon’. The remaining person was supported to do some activities at home. The service has had difficulty securing a college or day service placement for him due to funding issues but he has recently started a private placement one day a week and is Allan House DS0000004906.V366049.R01.S.doc Version 5.2 Page 14 enjoying this. A meeting has been held which highlighted the need for the person to access more services to improve his health and wellbeing. The manager fully acknowledged that the daytime opportunities provided by the home are limited however staff work very hard to seek stimulating activities. Discussions held with staff and records seen indicate that staff work flexibly to accommodate people’s leisure interests and to enable individuals to access day trips and holidays. One person told us that they are training for the Special Olympics and that she really enjoys her sport. Telephone discussions held with three other people indicate that they lead an active lifestyle and make use of their local community. People told us they use the local buses and the transport provided by the home to get out and about and also walk to local shops too. Everyone we spoke with told us they were all going away on holiday in July and really looking forward to it. People said that they have contact with their family and friends and it was reported that three people go home on a regular basis. One person said ‘I see lots of my family and my boyfriend’. People we spoke with also told us that go to evening clubs throughout the week to include swimming, basketball and a youth club. People also meet up with people who live at the provider’s other home too. Discussions with people who use the service indicate that daily routines are flexible. One person said ‘I go to bed when I want and I have a lie in at weekends. Staff knock on my door to get me up and I help keep my room clean, sometimes I go shopping and I help out with the tea and we have a rota so that everyone helps to do the jobs in the house’. People told us they like the food and can help choose what they want to eat and that they help plan the menus in the residents meetings. The menus seen was varied and appeared balanced and there was plenty of fresh fruit and vegetables seen in the kitchen. The manager told us that she would like to have the main kitchen, which is located on the first floor moved to the ground floor which would enble all people to get more involved in preparing meals. The person at home during our inspection helped lay the table for his lunch and appeared to enjoy the hot meal prepared for him. We advised the manager that it would be good if he could be more involved with basic meal preparation for example making his own sandwich under supervison. Support plans seen identified the peoples support needs for eating and maintaining health. Allan House DS0000004906.V366049.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 Quality in this outcome area is good The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. People living at Allan House are safeguarded by the home’s systems for handling, storing and administering medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Preferences in relation to support requirements were available on both files examined although these could be more specific for example one file stated that the person ‘is able to carry out most personal care tasks independently but requires prompts and supervision’. All of the people we spoke with appeared happy with the level of support that they receive. Discussions held with people using the service evidence that privacy and dignity is promoted although privacy screening is not available for two people who share a room. Discussion with a member of staff demonstrated a good understanding of privacy and dignity and how staff promote it during care provision for both individuals sharing a room. Allan House DS0000004906.V366049.R01.S.doc Version 5.2 Page 16 The self-assessment completed by the manager states ‘Our service provides access to outside agencies and medical professionals to work alongside the staff to promote healthcare support’. Care records seen and discussions held with the people we spoke with evidence that the home seek input from healthcare professionals in the best interests of individuals when necessary. All health appointments are recorded in addition to outcomes, although health action plans were not available. A member of staff spoken with considered the home meets the healthcare needs of individuals well and that people access all routine health appointments. Medication procedures were discussed with a member of staff who demonstrated a good understanding of how medication is managed in the home. The home uses the monitored dosage system for the people who are prescribed medication. Records for medication administered were found satisfactory and it was reported that there have been no errors with medication since the last inspection. Staff have access to a medication policy and procedure, information on drugs and possible side effects in addition to a homey remedy policy that has been signed by a general practitioner. It was stated that all staff have received training in administering medication however their on-going competency is not currently assessed. Allan House DS0000004906.V366049.R01.S.doc Version 5.2 Page 17 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): Standards 22 and 23 Quality in this outcome area is adequate People living at Allan House have access to a complaints procedure, which enables their views to be listened to. However the home will be better able to demonstrate its commitment to safeguarding people from abuse by updating the Abuse policy in line with current best practice and offer appropriate training to staff. The review of other policies and practices will also add safeguards to protect both the people living at the home and the manager and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who live at Allan House and their families have access to a complaints procedure, which was seen displayed in the reception area of the home. The procedure requires updating to reflect current information and the manager is looking to develop the policy in a user-friendly format. At the time of the inspection the complaint’s book had ‘gone missing’. The manager said that there had been no recent complaints. Surveys received from five people and discussions held with four people evidence that they have an understanding of what to do if they were unhappy with the service. One person said ‘I would speak to the manager, Alison’. Others said they would tell staff or go the manager. The AQAA stated that no referrals have been made to the Safeguarding Adults team and at the time of the inspection the manager was unaware of what the referral procedure was. There was evidence that on at least two occasions it Allan House DS0000004906.V366049.R01.S.doc Version 5.2 Page 18 would have been appropriate to refer incidents to this team but the home had not, despite working with outside agencies to investigate the one incident. Staff training records identified that not all staff had received training in ‘adult abuse’ or adult protection. It was stated however that the subject is covered in National Vocational Qualifications (NVQs). The manager confirmed that training is required in this area for some staff. She also stated that the Abuse policy is discussed during staff induction. The policy was later reviewed and found to contain only basic information and did not refer to working within local multi agency guidelines. Following the inspection the manager contacted us to say that she has now accessed the Supporting People Protection of Vulnerable Adults (POVA) Guidelines and is re writing her policies and procedures to reflect current good practice. She detailed a good understanding of the procedure and could recognise the shortfalls in the home’s current arrangements. She also stated that she will then be introducing the new procedures to all staff with immediate effect and is arranging more POVA training. Current arrangements for supporting people to access their money do not promote independence or offer safeguards to the manager who withdraws money on people’s behalf. The policy did not support current arrangements and records kept of transactions are not audited by anyone other than the manager. The manager recognised the vulnerability of these arrangements and is to review them with immediate effect. Allan House DS0000004906.V366049.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 Quality in this outcome area is good The people living at Allan House are provided with a clean, comfortable and homely place to live although they may benefit from the home being modernised to reflect their age range and lifestyles. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is located on the main road in Blythe Bridge and provides good access to community facilities and services. Accommodation is provided over two floors with all communal areas and five single and one double bedroom situated on the ground floor, which are lockable and have en-suite facilities. One of the people who shares a room indicated that he was happy with this arrangement. The main kitchen and office is on the first floor. People were happy to show us their bedrooms, which are personalised. One person spoken with said ‘I wish I could have a pink room instead of blue’. Another person spoken with said that she had just moved into a bigger bedroom and that she was happy with this. Allan House DS0000004906.V366049.R01.S.doc Version 5.2 Page 20 The home is maintained and decorated to a good standard however people may benefit from the home being decorated and furnished to reflect their age and lifestyle. This was acknowledged by those spoken with who reported that the home used to accommodate an older age range of people and that staff are now trying to modernise the home through the use of posters, photos etc. The home was found clean and tidy throughout and people spoken with said that they help to keep their home clean. A small laundry is provided however clothes have to be line dried or aired in a bathroom that is currently not used by people who use the service. Substances hazardous to health are appropriately stored and new data sheets and assessments have been obtained. Allan House DS0000004906.V366049.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 34, 35and 36 Quality in this outcome area is adequate People living at Allan House are supported by a team of staff who are able to meet their individual needs although improved supervision and induction processes will enable them to be more knowledgeable of processes and thus offer people better protection and support. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We spoke with the staff member on duty at the time of the inspection and she stated that she enjoyed her job and said that Allan House ‘Provides a good home and support & clients are happy where they live, they are protected and well looked after’. She felt well supported by the proprietors and the manager and had a good understanding of her job role. Although the staff member on duty said she had regular support and appraisals records did not support that this happens for all staff and discussions with the manager identified that she would like to improve formal staff supervisions, making them more regular. She is also looking to develop a more comprehensive induction package for new staff. The record of induction seen on the file of the latest staff member to join the team reflected that this process needs developing. Allan House DS0000004906.V366049.R01.S.doc Version 5.2 Page 22 The manager said that staff training has improved over the last twelve months She said that all staff have received mandatory training and also done training in developing risk assessments and care planning processes. Records reflected this although not everyone has received adult protection training and the manager is now addressing this. Staff on duty at the time of the inspection reflected the rota and it was seen that when people are all at home, for example on the last bank holiday, the manager arranges for extra staff to be on duty to enable people to go out. Staff files seen contained the majority of required information including confirmation that a person is ‘fit for work’. This had been a requirement made by us at the time of the last inspection. One of the two files reviewed was missing proof that a CRB had been received although the manager stated that no one works at the home until this has been received. There was however confirmation that a POVA First had been returned. The management does not currently have a staff development plan but will implement one to enable all information to be collated into one place and thus make monitoring outstanding training needs easier. Allan House DS0000004906.V366049.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): Standards 37, 39 and 42 Quality in this outcome area is adequate People living at Allan House benefit from having a management team who are committed to meet their care needs however some systems are making people potentially vulnerable and action taken to improve processes will improve the overall quality of the service. Quality assurance processes enable the home to identify people’s thoughts on the service provided and make changes to improve outcomes for people using the service. Effective health and safety checks mean that people can live in a safe environment. This judgement has been made using available evidence including a visit to this service. Allan House DS0000004906.V366049.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager of the home is experienced and was knowledgeable of the individual support needs of the people living at Allan House. She has attended courses to improve her knowledge and management skills and has plans to improve the home. Her aim is to be ‘excellent’ however she recognises that ‘as a small service there is a lot of work for the manager to do’. In addition the manager regularly works on shift. Requirements and recommendations made as a result of this inspection may suggest that more ‘management time’ is required to improve the overall quality of the service. The manager said that she receives good support from the proprietors. She said that they were in regular contact with the home and were contactable when they were off site. A review of the rota reflected that Mrs Jefferies regularly works on shift. Mr Jefferies was contacted at the time of the inspection when the manager reported a problem with the hot water within the home. The manager has developed an implemented a quality assurance process that involves obtaining responses to questionnaires about the home from people who live at the home, staff, relatives and health and social care professionals. Once these have been returned the manager reviews them and produces a breakdown of responses. The outcomes of the latest quality audit were seen to have been very positive. Where issues were identified the manager took action to address them. For example menus were reviewed when people said they would like more choice and this is now offered. Health and safety checks were seen to be up to date and the manager had been supported by a local fire officer to develop a fire risk assessment that included an evacuation plan. The manager reported that requirements made by the Environmental Health Officer had also been met. Health and safety records were well maintained and readily available for review. Accident records identified only minimal accidents within the home although the manager was advised to make better use of incident forms to save having to look back through daily records to find information. Allan House DS0000004906.V366049.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 2 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 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 2 2 3 X Allan House DS0000004906.V366049.R01.S.doc Version 5.2 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 YA1 Regulation 5(1) Requirement The home must develop a suitable service user guide that meets National Minimum Standards for care Homes For Younger Adults 1.2 and Care Homes Regulations 2001 Timescale for action 26/09/08 2 YA23 13 (6) Previous timescale 01/01/07 not met Policies and procedures must 25/07/08 safeguard people from abuse and reflect current legislation and best practice guidelines. This is to keep vulnerable people safe and also to protect the people providing the service. 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 YA1 Good Practice Recommendations The Home’s Statement of Purpose should be updated to reflect current management arrangements within the home and also ensure that other information included in DS0000004906.V366049.R01.S.doc Version 5.2 Page 27 Allan House 2 YA6 the document is up to date. To home should develop care and support plans that are more ‘person centred’ thus making them more userfriendly to the people they belong to Support plans should be more detailed and describe how all service users needs in respect of health and welfare are to be met. This will support staff to provide care in such a way as to ensure all service users needs are met. The home should use their pre-existing incident sheets (or develop a new format) to record any incidents that occur within the home. Information will then be readily available to help with the monitoring and review of behaviours that can challenge the service People who live at Allan House should have opportunities to develop their independent living skills within the home. The home should consider a programme of modernisation within the home to reflect the ages, preferences and lifestyles of the people who live there. Staff should be provided with training in safeguarding adults at the earliest opportunity to ensure they are familiar with the process of recognising potential abuse and the formal referral process. All staff responsible for the administration of medication should have their competency assessed on a regular basis. Staff should receive regular and recorded supervision for all staff in order to monitor performance and offer effective support and guidance The home should develop a training and development plan to identify training needs within the staff team. 3 YA6 4 YA6 5 6 7 YA17 YA24 YA23 8 9 10 YA20 YA36 YA35 Allan House DS0000004906.V366049.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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. 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