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Inspection on 18/05/05 for Autism Initiatives - Redpoll Lane

Also see our care home review for Autism Initiatives - Redpoll Lane for more information

This inspection was carried out on 18th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides comfortable, well-equipped accommodation that is homely; decorated and furnished in line with the resident`s personal needs and wishes. The atmosphere was relaxed and welcoming. Residents seemed relaxed in the environment; were able to make their needs known and interacted confidently with staff. Staff showed skill in their approach, interacting with both residents on an adult-to-adult level and reducing any anxieties with reassurance and diversion. Both residents join in a range of chosen activities including visits to shops, the pub, cafes and the swimming baths. Visitors are made welcome at all reasonable times, and support staff help the residents to keep family links and personal relationships whenever possible. Staff encourage residents to join in domestic routines and healthy eating is promoted by offering choice. Admissions into the home are carefully planned, with potential residents and their families able to "test drive" the home prior to moving in.

What has improved since the last inspection?

The temporary manager is addressing the requirements from the last inspection. Some progress has been made with staff training and risk assessment. Medication storage arrangements have improved. A guard has been fitted to a radiator in a resident`s bedroom to protect him from burns if he should fall against it, and the home`s fire fighting equipment has been serviced. Staff spoke highly of the temporary manager. A programme of formal one to one supervision has been introduced and morale is said to have improved. A quality assurance system has been established; a report detailing quality issues is available to the Commission for Social Care Inspection. The registered persons have begun a recruitment drive to attract a more localised work force through advertising vacancies in the local press and holding an open day in the local shopping precinct. Indications are that a lot of local interest has been shown for the jobs.

What the care home could do better:

Care plans, risk assessments and coping strategies must be regularly updated as, and when, residents needs change. This will ensure that staff provide the care and support for residents in a way which they prefer, and are familiar with. This is important to the well being and health of each resident. The medication systems need further improvement to ensure appropriate stock records and there should be enough suitable storage space for all medication. The home`s adult protection procedures must be improved to ensure that all staff including permanent, agency and casual staff know what to do if they see or suspect any abuse. The manager needs a current copy of Warrington Borough Council`s Adult Protection Protocol to give staff further guidance as to what action to take in the event of an incident or suspected abuse. Numerous staff changes in the recent past have included three different managers. The staff team was reduced to two part time staff; the majority of shifts being covered by agency staff or staff employed on a casual basis. These staff changes may prevent or affect continuity of care. The staff training arrangements have improved but none of the staff had an NVQ in care at level two or above. Some staff required training in medication and fire prevention. Action must be taken to recruit, train and retain an effective staff team to ensure the well being of residents.

CARE HOME ADULTS 18-65 AUTISM INITIATIVES 29 Redpoll Lane Birchwood Warrinton WA3 6NP Lead Inspector David Jones 18 and 19 th th Unannounced May 2005 12:00 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 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 Stationary 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. AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Autism Initiatives Address 29 Redpoll Lane Birchwood Warrington Cheshire WA3 6NP. Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01925-837004 Autism Initiatives Care Home 2 Category(ies) of LD - Learning Disabilities (2) registration, with number MD - MentaL Disorder (2) of places AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The 2 Service Users may be both LD and MD Date of last inspection 23 February 2005 Brief Description of the Service: Number 29 Redpoll Lane is located on a side road on a housing estate in a residential part of Warrington new town. The home is established to provide care specifically for younger adults with Autistic Spectrum Disorders. The home is a three bed roomed house with a lounge, dining room and kitchen on the ground floor and private gardens to the rear. Aids and adaptation have been provided to meet the needs of one resident. However, the premises do not provide level access and are not specifically designed to meet the needs of people who have a physical disability. Access to local shops and public transport is good and service users have their own car that is used on a daily basis. AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over 7 hours on 18th and 19th May 2005. Three staff members, the temporary manager and the two residents were spoken to. Discussion with the two residents was limited however, due to communication difficulties. Resident’s records and case notes were examined. Staff were supportive and interacted well with the residents. A tour of the gardens and parts of the building also took place. What the service does well: What has improved since the last inspection? The temporary manager is addressing the requirements from the last inspection. Some progress has been made with staff training and risk assessment. Medication storage arrangements have improved. A guard has been fitted to a radiator in a resident’s bedroom to protect him from burns if he should fall against it, and the home’s fire fighting equipment has been serviced. Staff spoke highly of the temporary manager. A programme of formal one to one supervision has been introduced and morale is said to have improved. A quality assurance system has been established; a report detailing quality issues is available to the Commission for Social Care Inspection. AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 6 The registered persons have begun a recruitment drive to attract a more localised work force through advertising vacancies in the local press and holding an open day in the local shopping precinct. Indications are that a lot of local interest has been shown for the jobs. 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. AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 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 standard(s) 2 and 4. New service users are admitted only on the basis of a full assessment undertaken by competent persons who involve the prospective service user, his/her family members and health and social care advisors. The home’s admissions procedures are well designed. The prospective service user is able to visit the home and become familiar with the environment, staff and other service users prior to admission. EVIDENCE: Reading of case records and discussion with management and staff confirmed that service users were admitted to the home after appropriate assessment and admission processes. These involved the service user, their family members and their health and social care advisors. Assessments seen were developed from initial care management assessments and were developed by the home’s monitoring and review arrangements. General review meetings that included the respective service users and their representatives were held every 6 months. AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 9 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 standard(s) 6 and 9. Care plans and risk assessments did not adequately confirm how each service users needs were being met. Without detailed and up-to-date care plans and risk assessments the continuity of care of each service users is reliant upon staff passing information on verbally. This is prone to miss-communication and therfore the continuity of care of each service user is jeopardised. EVIDENCE: The home’s assessment and care planning systems were designed to ensure that the service user and his representatives are placed at the centre of decision-making and the development of detailed and risk-assessed arrangements for care and support. However, it was evident that there had been a lack review and development of the care plans in recent months. Certain aspects of each of the two care plans seen had not been updated since 2003. Staff confirmed that arrangements to meet each service users needs’, including certain coping strategies had changed significantly. See requirement 1. Staff said that a strategy to minimise risks when travelling with both residents in the car had failed, as it tended to increase the resident`s anxiety and was therefore stopped. AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 10 Another strategy had been introduced but had not been written up or risk Case records and review assessed. See requirements 1 and 2. documentation showed that staff worked closely with each resident`s health and social care representatives. There was no record that professionals and or advocates had seen and agreed all parts of individual’s care plans and coping strategies. See recommendation 1. Some progress has been made to update and review risk assessments relating to the care and support of residents but further development is required as a number of these have not been reviewed since 2003. See requirement 2. AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 11 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 standard(s) 13, 14, 15, 16 and 17. Service users are enabled to lead ordinary lives, living in a house set within the local community and engaging in a range of dayday domestic and leisure activities. Staff support service users to maintain personal relationships and the daily routines of the house promote, independence and choice. Healthy eating, personal choice and involvement with meal preparation is promoted. EVIDENCE: The atmosphere was relaxed and sociable. Residents can visit and take advantage of opportunities presented to them in the local community. Each service user has a flexible activities programme covering the seven-day week that is designed to meet individual needs and personal preferences. Visits to community facilities include the pub, shops, parks, swimming baths and other places of interest. Plans for residents to go into the community, where unfamiliar people and places may present them with challenges, were detailed in the individual’s care plan. A number of the written strategies did not reflect the current arrangements in place to support residents whilst in the community or using transport. AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 12 Information from the temporary manager indicated that these strategies are under review. See previous sections of this report and requirement 1. Staff support service users to maintain family links in accordance with identified needs. One staff member has recently been designated as a key worker for one of the residents and said that she was going to introduce herself to family members. There was no contact with any visiting relatives during the inspection and residents were unable to comment on visiting arrangements due to communication difficulties. However, discussion with staff indicated that visitors were made welcome at all reasonable times. Staff demonstrated skill in their interactions with residents, offering timely prompts to enable everyone to be relaxed and to join in ordinary domestic activities. Staff foster daily routines that promote independence, individual choice and freedom of movement within the home. Residents are relaxed within the home’s environment and one spoke positively of the staff indicating satisfaction with his care and support. Staff were aware of individual’s likes, dislikes and personal preferences and involved them in meal preparation. Healthy eating is promoted and service users’ rights to exercise choice is respected and encouraged. Menus were not used as residents can choose their meals from the fridge, freezer and food stores. Records of meals indicated a varied and nutritious diet was offered. AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 20. Action had been taken subsequent to the previous inspection to improve the home’s medicines storage facilities but these remained inadequate and required further improvement to ensure the safe storage of medication. Records of the stocks of loose medicines received into the home were not routinely maintained, medication was missing and therefore service users were not adequately protected. EVIDENCE: A medications check showed that medicines were administered and recorded appropriately, but records for loose medicines in the home were not made and maintained. A monitored dose medication system is provided by a local pharmacy. Staff responsible to administer medication had received training from the pharmacy with the exception of two. The temporary manager indicated that training had been arranged for all existing staff and new recruits. The temporary manager also advised that new proprietary medicines cabinets were on order. In the meantime, two small medicines cabinets have been fixed to a solid wall, but are too small, so medicines remain stored in the locked filing cabinet. See requirement 3. AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 14 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 standard(s) 23.The home’s policies and procedures on adult protection and arrangements for their implementation are not sufficiently robust to ensure the protection of service users. EVIDENCE: Allegations of misconduct including abuse of residents from two staff members were made, prior to the 1st April 2005 inspection. These staff members have been suspended, to maintain the protection of vulnerable adults, whilst an investigation is carried out. The local authority’s Adult Protection Procedures had been followed. However, delays in the adult protection process were identified, questioning the effectiveness of the home’s adult protection policies and procedures and arrangements to implement them. It was clear that the staff making the allegations had been concerned for some months and had failed to report their concerns in line with the home’s policies and procedures. More delays in notifying the local authority and starting local adult protection protocols in accordance with the Department of Health Initiative “No Secrets” were also apparent, when senior managers failed to notify the CSCI within 24 hours and started an internal investigation outside of the local adult protection forum. These issues were raised with the line management of the Company before this inspection and it was agreed by the corporate Director of Autism Initiatives that the organisation’s policies would be reviewed to ensure consistency with local adult protection protocols. The home has a copy of the internal adult protection policy, which includes reference to the Department of Health guidance ‘No Secrets’ and also has a draft copy of the local authority’s adult protection procedures. Staff spoken AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 15 with had not received training or guidance in how to implement adult protection procedures. While they knew the procedures existed, they were not familiar with them. The front sheet of the home’s adult protection policies and procedures includes a list of staff who have seen and read the respective documents. It was noted that none of the staff currently working at the home had signed the adult protection policies. See requirement 4. It is recommended that the current version of the local authority’s adult protection procedures is acquired for future reference. See recommendation 2. AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 16 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 standard(s) 24,25, 26, 27, 28, 29 and 30. Service users live in a homely, clean and comfortable environment that has been equipped, decorated and furnished to meet personal requirements. EVIDENCE: The home is spacious, bright, cheerful, airy and clean throughout. The premises are in keeping with the local community and the style and atmosphere reflects the home’s purpose. The accommodation has two reception rooms and an enclosed rear garden, which staff and residents maintain. The premises are well maintained and appropriately decorated throughout. Residents bedrooms are decorated and furnished to reflect individual needs and personal preferences. Staff were re-decorating residents bedrooms and had involved them in choosing the décor. A radiator guard had been fitted to a radiator in one of the resident`s bedrooms in line with the risk assessment. The fire extinguishers had been serviced since the last inspection. A separate toilet is on the ground floor and a bathroom with toilet, shower and bath on the first floor. Handrails and a toilet frame were provided for a resident to maximise his independence. The toilet frame in the ground floor toilet was rusting and requires re-painting or replacement. See recommendation 3. AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 and 36.Staff are provided in sufficient numbers and some progress had been made to address staff training needs. However, there was a high usage of agency staff with little evidence that they had been appropriately inducted. This coupled with some outsanding training needs amongst the staff group could result in a lack of continuity of care and support for service users. EVIDENCE: Staffing rotas, discussion with the temporary manager and staff confirmed that appropriate numbers of staff are employed for the assessed needs of the service users. The staffing team is made up of a full time Team Leader post (Registered Manager) and five full time Support Worker posts. Due to unforeseen staff movement in the home, it is currently running with just two part-time permanent staff members. There was one full time “casual” member of staff who has worked consistently at the home 30 hours each week and a number of others who are also employed by Autism initiatives on a casual basis or were appointed via an agency. Staff raised concerns about the high usage of agency staff and the negative impact this may have on continuity of care for residents. Continuity of care and support is central to the needs, health and mental wellbeing of each resident. An increase in a service user’s self-injury has been identified in recent weeks. AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 18 Case records showed that health care advisors indicated that recent staff changes may have been a contributing factor to the increase in this behaviour. See requirement 5. Autism Initiatives has made good progress in recruiting staff from the Warrington Area from an open day in the local shopping centre and advertisements in the local press. This has resulted in a number of job applications from local people and interviews were currently being held. In keeping with good practice, the deputy manager has tried to use agency staff who are familiar with the home and the residents` needs. As such staff are not always available one staff member had worked a continuous 60-hour shift, broken only by sleep–in duties. This shift started at 9am on a Tuesday morning until 9pm on the following Thursday evening. The staff member did not seem adversely affected by tiredness but was only partway through the shift. Consideration should be given to limiting the number of consecutive shifts a staff member works as the support worker`s role may be demanding and stressful. Working many shifts together may adversely affect a member of staff’s capacity to meet residents` needs. See recommendation 4. Staff records and information from the temporary manager showed that none of the staff currently working in the home had an NVQ in care at level 2 or above. See recommendation 5. Some progress has been made to address staff training needs from the previous inspection with some staff having received recent training in fire prevention and health and safety. Arrangements had been made for other training including medication, first aid, basic food hygiene and fire training for those needing it. It was also noted that some staff had not received training in Adult Protection procedures. See requirements 4 and 6. The temporary manager has implemented an induction checklist for all new agency staff before working in the home. These documents indicated that the induction of some agency staff was only partly complete. An agency worker, who had previously worked there on ten occasions, said that he was unfamiliar with the care plans and had not read them. See requirement 6. One staff member said that no scheduled supervision had been given within the last 12 months. Another staff member said that the temporary manager intended scheduled supervision would be offered to all staff every month. See recommendation 6. The induction checklist for agency staff did not include adult protection procedures as recommended. See recommendation 7. No new staff were recruited into the home since the last inspection. The temporary manager indicated that the most recent staff member had started a structured induction and was currently working through a workbook. All new recruits are appropriately inducted and supervised prior to working unsupervised in the home. AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 39, and 42. Service users benefit from the management approach of the home, which creates an open, positive and inclusive atmosphere. EVIDENCE: In the absence of the designated home manager, a temporary manager is responsible for day-to-day management, with direct supervision from the locality manager. The requirements and recommendations for the training and developmental needs of the designated manager could not be addressed. Progress was being made to address staff training needs, introduce planned supervision and appropriate induction of agency staff, but further development is required to ensure that staff are appropriately trained and supervised. See previous sections of this report and requirements 4, and 6 and recommendations 5 and 6. AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 20 Staff indicated that the temporary manager was accessible, supportive and provided direction and leadership. Morale in the home was said to be buoyant with staff looking forward to positive developments in the home’s assessment and care planning processes. A quality assurance monitoring system has been introduced since the last inspection, and a report detailing the action taken to address quality issues made available to the CSCI, the residents and their representatives. Satisfactory action has been taken to control the dangers to a resident from an unprotected radiator and an appropriately qualified engineer has inspected and serviced the fire extinguishers. AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 21 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 x 3 x 3 x Standard No 22 23 ENVIRONMENT Score x 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 2 Standard No 11 12 13 14 15 16 17 x x 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 2 2 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 AUTISM INITIATIVES Score x x 1 x Standard No 37 38 39 40 41 42 43 Score x 3 3 x x 3 x F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 22 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 YA6 Regulation 15 Requirement Timescale for action 30.06.05 2. YA9 and YA6 13 and 15 3. YA20 13 & 17 4. YA23 13 The registered persons must ensure that care plans are reviewed and updated at appropriate intervals and as and when the needs of service users change. The registered person must 30.06.05 review risk assessments as part of care plans to ensure that described control measure reflect how the respective service user’s needs would be met. (Previous timescales 060804 and 31/03/05 not met.) The registered persons must 30.06.05 provide appropriate storage for medication, affixed to a solid wall with the appropriate fittings, and in addition must ensure that all staff involved in the handling and administration of medication are suitably trained. (Previous timescale 31/03/05) not met. stock records of loose medecines must also be maintained in the level of detail that would allow a stock check to be made. The registered persons must 30.06.05 ensure the protection of service users by the implementation of robust adult protection Version 1.30 AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Page 23 5. YA33 18 6. YA32 18 procedures including training of staff in adult protection issues and action to take on witnessing or having suspicion of abuse. The registered person must ensure that the employment of staff on a temporary basis at the home does not prevent service users from receiving such continuity of care as is reasonable to meet their needs. (Previous timescales 060804 and 31/03/05 not met.) The registered person must review staff training needs and subsequently take appropriate action to ensure that all staff are appropriately trained and skilled and agency staff are appropriately inducted and familiarised with care plans and adult protection procedures. Particular attention must be given to the training of staff in Fire Prevention procedures, food hygine and First Aid. (Previous timescale 31/03/05 not met.) 30.06.05 31.07.05 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 YA9 Good Practice Recommendations The registered persons should ensure that coping strategies including risk assessments are agreed with the respective service user’s advocates including health and social care professionals and their agreement is recorded and dated. The registered persons should acquire an up-to-date copy of the local authority’s adult protection procedures for the information of staff and other interested parties. The registered persons should re-paint or re-place the toilet frame in the ground floor WC. The registered persons should consider limiting the F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 24 2. 3. 4. YA23 YA26 YA33 AUTISM INITIATIVES 5. 6. YA32 YA36 7. YA33 number of consecutive shifts staff are permitted to work to ensure they are protected from the cumulative affects of stress and fatigue, which may have an adverse effect on their capacity to meet service users’ needs. The registered person should ensure that at least 50 of staff achieve NVQ level 2 or above within the near future. This will include agency staff. The registered person should ensure that all staff including agency staff benefit from the home’s staff support systems including scheduled supervision at the appropriate frequencies The registered persons should further develop the home’s induction procedure for agency staff to include familiarisation with the home’s adult protection procedures. AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Unit D, Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 AUTISM INITIATIVES F51 F01 S27045 Redpoll Lane V226542 180505 Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!