CARE HOME ADULTS 18-65
Bawden Manor Farm West Polberro St Agnes Cornwall TR5 0ST Lead Inspector
Lowenna Harty Unannounced Inspection 09:30 21 December 2005
st Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Bawden Manor Farm Address West Polberro St Agnes Cornwall TR5 0ST 01872 552237 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) bawden.manor@deact.ev.com Spectrum Mr Christopher Halford Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 7th June 2005 Brief Description of the Service: Bawden Manor Farm is a care home providing accommodation and personal care for up to 7 adults of both sexes, with a learning disability. The registered provider is Spectrum, an organisation that specialises in providing services to people with autistic spectrum disorders. Spectrum employs a manager and a team of care staff to run the home on a day-to-day basis. Senior managers from the organisation are available to provide specialist input and support to service users as required. The home is a detached, two-storey building, set in its own, extensive grounds. It has a spectacular view of the Cornish coastline. All of the service users have individual bedrooms and have access to a large, communal lounge. There is a smaller, quiet lounge and separate dining room. The home has a separate kitchen between the main lounge and the dining room. The home has separate office facilities with space for staff to sleep in. The main entrance is accessible by steps, but the home has a separate entrance with level access and there are bedrooms on the ground floor of the building. The building could be adapted to meet the needs with physical disabilities if necessary. There are already some adaptations in place to meet the needs of people with sensory disabilities. The home is in a quiet, secluded area on the outskirts of the village of St. Agnes. The village centre is within walking distance and local towns are accessible by car. Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on 21 December 2005 and lasted for approximately six hours. The purpose of the inspection was to ensure that service users’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus is on ensuring that service users’ placements in the home result in good outcomes for them. The inspection consisted of an inspection of the premises, examination of care, safety and employment records and discussion with the home’s manager and senior staff. There were opportunities to observe the daily life of the home and staff interaction with the service users. The principle method of inspection was case tracking, which involves reviewing the care records for selected service users in detail and following this through with interviews with them and staff working with them. Two service users were case tracked at this inspection. The home provides an improving standard of care to the service users placed there, which they confirmed during the interviews and was apparent in the records held in the home to support good care practices. What the service does well:
Since the previous inspection, two new service users have moved into the home, from another Spectrum home. They were given good information about their new home and visited it several times before moving in, to make sure it would be suitable for them. Service users have written care plans, which set out their individual needs and consider their abilities to make decisions for themselves. These consider their personal, health and social care needs, relationships, interests, abilities and cultural backgrounds. Service users are encouraged to participate in the day-to-day life of the home, including helping out with household tasks and shopping so that they can
Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 6 develop their independence, confidence and skills. Staff help them by working alongside them. They are encouraged to eat varied and balanced diets, with mainly homeprepared foods so that they stay physically healthy and enjoy their meals. Staff help service users to go shopping for household items and prepare meals to develop their skills. Staff help service users to keep themselves looking clean, tidy and physically presentable. They are encouraged to maintain their own personal care and hygiene, as far as possible. Where they need support, staff have detailed written instructions and ensure they receive care in private. Care staff currently have or are working towards achieving formal qualifications in care, so that service users and their representatives can have more confidence in their skills and abilities to work with them. There are records in the home to demonstrate that care staff are recruited on the basis of fair and effective recruitment practices and are suitable to work with vulnerable adults in a care setting. Staff are well supported and supervised in their work. They do not work alone or in isolation and have good access to managers and senior staff at all times. They have formal supervision and attend team meetings regularly, so that they have opportunities to reflect on their care practices and training needs for the benefit of service users. The home’s manager has a formal management qualification and is experienced as a manager of another Spectrum home, prior to taking up his current employment at Bawden Manor Farm. He has already introduced changes and improvements to the home. Service users’ personal records are held securely for them and they are informed of how they can access them if they wish. Records needed for the welfare and protection of service users are now held in the home and are kept up-to-date. There are systems in place to protect the health and safety and welfare of service users and staff working in the home, including written risk assessments conducted by the home’s manager, access to training and written procedures in place to guide staff in their care practice. What has improved since the last inspection? Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 7 Key information about the home and the terms and conditions of service users’ placements have now been provided to them in translated formats, including photographs and symbols. This means that they can be much more personally and directly involved in making important decisions about their lives. There have been noticeable improvements to service users’ care plan formats to make them more personalised and individual to each service user. They are provided to service users in alternative formats so that they can more easily access the information and kept available for them to read. Service users appear to be taking part in a greater range of activities in and out of the home, which are more in line with their individual care plans and interests. The service users whose cases were tracked at the time of the inspection attend college or work placements outside of the home during the week. Service users were taking part in different activities in and out of the home at the time of the unannounced inspection. Service users guides, with information on the terms and conditions of their placements in the home have been given to them in translated formats so that they are clearer about their rights and responsibilities. Their care plans also set out their rights in relation to personal information, which is held about them, so that they are better informed. There are improved systems to ensure that service users’ medicines are managed properly, in ways that reduce the risk of their suffering harm as a result of medication errors. Recording systems are clearer and mean that sources of errors can be more readily identified, for example, and written procedures now commence with the assumption that service users should be able to manage all or some aspects of their own medicines. Service users now have improved information on how they can go about making a formal complaint if they are not satisfied with the care and services provided to them at the home. They have copies of the complaints procedure in translated formats, so that they can access the information directly, if they wish. The development of a greater range of communication methods in the home has meant that their views can be more easily heard and taken account of. There have been some improvements to the home’s environment to make it more comfortable for service users. There are new settees in the main lounge and new chairs are on order. Since the previous inspection, there has been an increase in the number of staff working in the home so that each service user now has two key workers. There were plenty of staff in evidence at the time of the inspection, constantly interacting and working directly to support the service users. Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 8 What they could do better:
Service users’ care plans should have more specific goals so that they and their representatives can be clearer about the aims of their placements in the home and can monitor their progress as they achieve skills and greater independence. Whilst there has been considerable improvement to assist service users develop their communication skills, using a range of materials, they should be assisted to access specialist support in this respect, if they would benefit from it. If there is evidence that they would not benefit, the reasons should be clearly explained to them and/or their representatives. Currently only one service user has an independent advocate to oversee their welfare and best interests. Whilst most have input from relatives and/or representatives of their placing authorities, they should be fully enabled to access support independently, particularly where they have difficulties in communicating their needs and preferences. More staff should be provided with access to safe handling of medicines training to complement the training provided in-house by Spectrum and the new pharmacist for the service. This would reduce risks of service users being harmed by medication errors, as staff would be better informed about how best to protect them. Whilst there are good systems in place to ensure that service users are protected from neglect, self-harm and abuse, they would benefit from specific improvements. The home’s internal procedures should be reviewed and updated, so that they reflect the most recent changes in the law and good practice. There should be copies of the procedures of service users’ placing authorities so that staff can refer to them if they suspect abuse of a vulnerable adult. The home’s manager and senior staff should attend multi-agency training in the protection of vulnerable adults so that they can familiarise themselves better with the roles of other professionals in this and pass this knowledge on to other staff working in the home. Further improvements are needed to make the home’s environment more comfortable and homely for service users. Most noticeably, a bedroom currently used for service users to attend the home for short-stays needs to be redecorated and provided with a suitable window cover, as there is none at present. The kitchen units and worktops should be replaced, as they appear old and worn. Although the home appeared clean and tidy at the time of the unannounced inspection, there remains a risk of cross-infection because of the lack of laundry facilities to disinfect heavily soiled materials. Staff need to be provided
Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 9 with training to supplement the written guidance they are given to prevent the risks of infections spreading in the home. Records of staff training should be clearer, for inspection and planning purposes and to provide full evidence that staff have undergone induction and subsequent training that they need to effectively work with service users. The home’s current manager needs to be registered formally with the Commission as fit to manage the home, to reassure service users and their representatives of his competence and authority. Formal systems to review the quality of the services provided by the home need to be improved so that service users and their representatives can be confident that their views and needs underpin the ongoing development of the home. This includes regular visits to the home by Spectrum’s senior managers with reports to the Commission on how well the home is meeting service users’ needs. Specific improvements are needed to ensure the health and safety of service users and staff, in respect of fire safety. Fire alarms and safety equipment need to be tested weekly, with records kept so that service users can be confident they will be protected from the risks of fire in the home. Records of staff training in the home’s fire safety procedures need to be clearer so that the home’s manager can keep track of them and ensure they are all aware of what they should do to protect service users and themselves in the event of a fire in the home. 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. Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 10 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 Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 11 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&5 Prospective service users have good information on which to make a decision as to whether the home would be suitable for them. All service users have written contracts and statements of terms and conditions so that they are aware of their rights and responsibilities. EVIDENCE: There is information about the home, in translated formats so that service users can access it directly and this has been provided to all service users, including those who have moved into the home since the previous inspection. Information is held in individual containers so that they can access it whenever they wish. Service users who have recently moved into the home undertook a series of visits to the home, so that they could see it and familiarise themselves with it, before moving in. There are copies of service users’ individual contracts with statements of the terms and conditions of their placements in the home on each of their personal files. Information is translated into alternative formats for service users to access directly, where this would be helpful for them. Service users’ representatives have signed their contracts in the case of those who have recently been placed in the home. Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 8 Service users have written care plans but further improvements are planned to communicate the information more effectively to them. Service users are encouraged to make decisions about their lives but would benefit from specific assistance to help them to do this in a more active way. They are encouraged to participate in the daily life of the home so that they can develop their independence, confidence and skills. EVIDENCE: New care plans have been introduced, which are much more person centred and personalised. These are provided in translated/ pictorial formats and are kept available so that service users can access them when they wish. Service users and their representatives are invited to sign up to them as evidence of their participation and agreement. Care plans cover all service users’ personal, social and healthcare needs, including issues relating to their religious and cultural backgrounds and personal relationships. The new plans are still in development and are being rolled out to cover all of the service users. Further work is planned to include more specific goals for service users so that they can be clearer about the aims of their placements in the home. Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 13 There has been considerable improvement in development of new techniques to help service users to communicate their needs and preferences so that they can be more actively and directly involved in making decisions about their lives. Their care plans consider their communication needs and skills in making decisions. Service users should be assisted to access specialist assessments with regard to their communication needs, if they would benefit from them. If this is not the case, there should be clearly recorded reasons, to ensure that they are assisted to access the most appropriate communication equipment for their individual needs. Service users are encouraged to develop their skills and independence by taking active roles in the daily life of the home, in accordance with their care plans. This includes assisting in household tasks and shopping, with staff assistance, as necessary. Service users maintain their own daily care records, with staff assistance, if they need it, to show how their care plans are carried out on a day-to-day basis. Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 14 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 16 & 17 Service users take part in a variety of activities during the week, depending on their individual needs, abilities and preferences. Service users have been appropriately informed of their rights and responsibilities in respect of their placements in the home, but may benefit from further assistance in this. They are encouraged to maintain a varied and balanced diet so that they remain physically healthy. EVIDENCE: Service users’ written care plans and daily care records provide evidence of the different activities they participate in during the week. There are records of their individual likes, dislikes and preferences. Staff were observed assisting them to participate in individual activities in and out of the home at the time of the inspection. Service users’ statements of the terms and conditions of their placements in the home are contained in their service users’ guides and are provided to them in appropriately translated formats so that they are more aware of their rights and responsibilities. The new care plans set out their rights, for example, in relation to the Data Protection Act, more clearly. Only one service user currently has an independent advocate, separate to their family and placing
Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 15 authority representatives. Other service users, who would benefit, should be provided with access, particularly those with communication difficulties, so that there is independent oversight of their best interests and welfare. Service users interviewed at the time of the inspection said that they are satisfied with the food provided to them. There are written records of their dietary needs and food preferences. There are records of menus and meals served in the home, which show how they are encouraged to maintain a healthy, balanced diet, with plenty of variety and home-prepared foods. Service users are encouraged to participate shopping and food preparation for the home. Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 20 Staff help service users with their personal care and hygiene to develop their independence. There have been notable improvements but specific improvements are needed to protect service users from medication errors. EVIDENCE: Staff support service users with their self-care, depending on t heir skills and abilities, which are recorded in their individual care plans. There are detailed instructions for staff on how to help them, particularly those who need more support. Service users appeared to be well cared for, clean and presentable in their personal appearance at the time of the unannounced inspection. There are sufficient bathrooms for their personal care to be attended to in private. There have been notable improvements to the home’s systems for managing service users’ medication. This includes a new, written procedure, which allows for service users to take responsibility for all or some aspects of their medicines management. Improved systems for administration and recording of medicines have been introduced. Some staff have already received training in the new systems and others are booked to attend shortly but those handling medicines should undertake more in-depth training in the safe handling of medicines to protect service users from medication errors, in addition to the short-courses provided by the pharmacist.
Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 17 Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 There are formal and informal systems in place to ensure that service users’ views are properly taken into account. Specific improvements are needed to protect them from abuse, neglect and self-harm. EVIDENCE: Service users have now been given copies of the home’s formal complaints procedure in formats they can access directly, so that they are more aware of how to make their views and concerns known. The introduction of a greater range of communication methods has meant that service users’ views can be more easily taken account of in the day-to-day life of the home. There is written evidence that staff working with service users are recruited on the basis of fair, safe and effective recruitment and selection practices and are suitable to work with vulnerable adults in a care home setting. They rarely work alone with service users and there were plenty of staff on duty at the time of the inspection. Spectrum needs to update its internal written procedures to guide staff on the protection of vulnerable adults from abuse. There are copies of the written procedures from the local authority but procedures from service users’ placing authorities should also be obtained. The home’s manager and senior staff should attend local multi-agency training on protecting vulnerable adults so that they and staff working in the home can be more confident of how to proceed should they suspect a service user has been abused. Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Improvements are needed to make environment more comfortable, pleasant and hygienic for service users EVIDENCE: There have been some improvements to the home’s environment since the previous inspection and there is an ongoing maintenance programme for the home. The main lounge has new settees and new chairs have been ordered. Several improvements are needed to make the home more comfortable and pleasant for service users. One of the bedrooms, used for service users who stay at the home for over-night or short-stay respite care needs redecoration as the paintwork is worn and chipped. This room also requires a suitable form of window cover, as there are no curtains. The kitchen units and worktops should be replaced as they have become worn, particularly in light of the number of people now using the building. The home appeared clean and tidy at the time of the inspection. There are written procedures on infection control to guide staff and they are provided with some protective equipment, such as dissolving sacks for soiled laundry. The home does not have sluicing facilities or a washing machine that allows for disinfection of heavily soiled laundry. This is needed, on the basis of some service users’ records and because of the number of people using the home.
Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 20 Care staff should be provided with adequate training in infection control to be able to effectively reduce risks of cross-infection in the home. Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 The home’s staff team has increased considerably since the previous inspection so that at the time of the unannounced inspection there were plenty of staff on duty in the home. There are currently sufficient staff for each service user to have two key workers. They were working directly with service users throughout the inspection. Staff are working towards achieving formal qualifications to reassure service users that they are competent to work in a care setting. Service users are protected by the home’s recruitment policies and procedures, which are fair, safe and effective. Staff need improved access to training, which should be properly planned to benefit service users. Staff are well supervised and supported so that they do not work with service users with complex needs in isolation. EVIDENCE: Most of the staff either have or are working towards achieving qualifications to at least NVQ level 2. The manager is confident that they home will soon progress to the 50 level recommended in the National Minimum Standards. There are some records available to support this, but they are not readily accessible. Spectrum has introduced a secure computerised record system and now has full evidence to suggest that staff are recruited on the basis of fair selection procedures and are suitable to work in a care setting with vulnerable adults. Records are readily available on the home’s computer and are updated regularly.
Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 22 Induction records and training records and plans for the staff team as a whole are not clear or easily accessible, so it was difficult to ascertain what training staff had completed and what they needed. There should be a training plan for the team as a whole so that the manager can ensure there is an appropriate mix of staff with different skills at all times. Whilst staff have good access to training they should have access to training in infection control and safe handling of medicines, as previously mentioned in this report. These courses do not currently feature on the home’s training calendar. Staff do not work alone or in isolation. There are records of formal supervision held individually with them on a regular basis and of team meetings, pending the introduction of a more formal appraisal scheme in the future. Staff have opportunities to reflect on their care practices and training needs in relation to their work with service users. Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 A specific improvement is needed to reassure service users that they are living in a well run home. Improved systems for quality control are needed so that service users can be confident their views and best interest underpin the home’s continuing development. Service users are well protected by the home’s record keeping policies and procedures. Some improvements are needed to ensure their health and safety. EVIDENCE: The home’s current manager is qualified to NVQ level 4 in management, has been employed with Spectrum for over eight years and was previously registered as manager of another Spectrum home. He undertakes regular training to update his knowledge and skills and has already made improvements to the home. He needs to apply to be formally registered as manager, with the Commission, to reassure service users of his competence and authority to manage to the home. There is a lack of a coherent, formal quality control system in place to reassure service users that their views and interests are fundamental to the home’s
Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 24 ongoing development. Service users and their representatives should be formally invited to provide their views on the quality of services provided at the home and the results linked to the home’s annual business and development plan. This should be published and circulated to service users and external stakeholders. Records of visits to the home by Spectrum’s senior managers need to be sent to the Commission each month, which has not happened, despite the requirement set at the previous at the previous inspection. Records required by regulation for the welfare and protection of service users are available in the home on the basis of those reviewed at this inspection. They are securely stored and service users are advised on how they can access them in accordance with the Data Protection Act. The home is mainly safe. The fire safety risk assessment has been completed and there are records of regular evacuation drills. The home’s environmental risk assessment has been completed and staff have written procedures to guide their practice with regard to health and safety. They have good access to ongoing training in most aspects of health and safety. Tests of the home’s fire alarms and safety equipment need to be undertaken and recorded on a weekly basis, where this is indicated and there need to be clearer records to demonstrate that all staff have undergone instruction in the home’s fire safety procedures. Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 3 X X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X X X X 2 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Bawden Manor Farm Score 3 X 2 X Standard No 37 38 39 40 41 42 43 Score 2 X 2 X 3 2 X DS0000008966.V273685.R01.S.doc Version 5.0 Page 26 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA30 Regulation 13(3) Requirement Timescale for action 15/01/06 2. YA37 8 3. YA39 24 5. YA39 26 Suitable arrangements must be made to prevent the risk of the spread of infection in the home with particular reference to washing machine facilities/ arrangements for laundering heavily soiled materials that require disinfection. This requirement has been renotified. Previous dates have been set for compliance by 30/04/05 and 30/07/05 and have been exceeded. An immediate requirement for compliance was set at this inspection and will be followed up by the Commission directly with Spectrum. A manager registered with the 01/04/06 Commission must be appointed to manager the home on a dayto-day basis. There must be a coherent 01/04/06 system for reviewing the quality of care provided to service users, the results of which must be shared with them and their representatives. Reports of visits to the home by 01/01/06 Spectrum’s senior managers
DS0000008966.V273685.R01.S.doc Version 5.0 Bawden Manor Farm Page 27 6. YA42 23(4) 7. YA42 23 (4) must be submitted to the Commission on a monthly basis. This requirement is re-notified because full compliance has not been achieved since 30/07/05 Tests of fire alarms and safety equipment must be undertaken on a weekly basis, where this is indicated, with records maintained. There must be clear records to indicate that all staff have been instructed in the home’s fire safety procedures. 01/01/06 01/01/06 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. Refer to Standard YA6 YA7 Good Practice Recommendations Service users’ care plans should have clearer written goals relating to the aims of their placements in the home. Service users with communication difficulties should be assisted to access specialist services to help them to develop their skills, if they would benefit from them. If this is not the case, they should be provided with clearly documented reasons. Service users should have independent advocates, particularly those with communication difficulties. Staff handling service users’ medication should undergo training in the safe handling of medicines. The home’s internal written procedures for the protection of vulnerable adults from abuse, neglect and self-harm should be reviewed and updated. Copies of inter-agency policies and procedures for the protection of vulnerable adults from abuse from each of their placing authorities should be held in the home. The home’s manager and senior staff should attend local multi-agency training in the protection of vulnerable adults from abuse. Specific improvements should be made to the home’s environment including re-decoration of the respite care room and provision of suitable window covers and
DS0000008966.V273685.R01.S.doc Version 5.0 Page 28 3. 4. 5. 6. 7. 8. YA16 YA20 YA23 YA23 YA23 YA24 Bawden Manor Farm 9. 10. 11. 12. YA30 YA35 YA35 YA39 replacement of the kitchen units and worktops. Care staff should be provided with training in infection control. Evidence of staff induction and training completed by them should be more readily available for inspection and planning purposes. There should be a whole staff team training profile to assist the planning of staff training. The home’s annual business plan should contain costs and be more clearly linked to an annual development plan for the home, based on quality assurance measures and positive outcomes for service users. Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Bawden Manor Farm DS0000008966.V273685.R01.S.doc Version 5.0 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
