Inspection on 11/10/05 for Bedrock Court

This inspection was carried out on 11th October 2005.

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

Other inspections for this house

Bedrock Court 11/11/08

Bedrock Court 27/11/07

Bedrock Court 05/06/07

Bedrock Court 07/11/06

Bedrock Court 14/06/06

Bedrock Court 16/02/06

Bedrock Court 24/03/05

Bedrock Court 02/12/04

Bedrock Court 28/01/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 The Gables 3 New Road Stoke Gifford South Glos BS34 8QW Lead Inspector Paula Cordell Unannounced Inspection 09:30 11 & 14 October 2005 th th The Gables DS0000003366.V250657.R02.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 The Gables DS0000003366.V250657.R02.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. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Gables Address 3 New Road Stoke Gifford South Glos BS34 8QW 0117 9798746 01454 772171 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) Mr John Michael Gay Mrs Angeline Linda Gay To be appointed Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (1), of places Mental Disorder, excluding learning disability or dementia - over 65 years of age (1) The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 6 persons aged 19-65 years requiring personal care only May accommodate up to 1 person with Mental Disorder who may be under 65 years or over. 24th March 2005 Date of last inspection Brief Description of the Service: The Gables is one of three homes operated by Nightingale Care Homes. All three homes are owned and operated by the proprietors, Mr and Mrs Gay. The other homes within the group are Bedrock Lodge and Springfield. The Gables is a mature detached house and is registered with the Commission for Social Care Inspection to provide personal care and accommodation for six people with a learning disability aged between 18 and 65 years of age with one person over the age of 65. In addition the home may accommodate one person with mental health issues. The home is situated within close proximity of the Avon Ring Road. There are bus routes approximately 300 yards from the home. There are local shops and the home is within easy reach of Bristol Parkway railway station. Accommodation is on two floors. Presently the home does not have a registered manager. The Gables DS0000003366.V250657.R02.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. The purpose of the visit was to monitor the progress to the requirements from the last inspection in March 2005 and review the standard of the care provided to the residents at The Gables. The inspection was conducted over two days by two inspectors for a total of 16 hours. In addition, three anonymous complaints were received by the Commission for Social Care Inspection and were investigated as part of the inspection process, as agreed within a protection of vulnerable adults strategy meeting. The findings of the complaint will be detailed in this report. There have been no additional visits since the last inspection. The provider has been sending reports of the monthly regulation 26 visits and these were used to plan the inspection process. What the service does well: What has improved since the last inspection? There has been little progress on the requirements made at the last inspection and, whilst there was evidence that some areas have improved, there is still work to be completed for the home to demonstrate full compliance with the National Minimum Standards and the Care Home Regulations to ensure that this is a safe and well-managed home. The home has developed a statement of purpose but this requires more detail to ensure it meets with the legislation and reflects the service that is available to the individuals living in the home. Whilst some effort has been made to review the care plans only three of the six had been reviewed. This has been an outstanding requirement since 28th July 2004, December 2004, March 2005 and now October 2005. Enforcement action is being taken and statutory notices of compliance will be sent to the home. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 6 Residents now have information available to them to make an informed decision about whether to move to the home, including detailing the arrangements for prospective residents to visit the home prior to admission. This still needs some fine-tuning to ensure compliance with the regulations. Whilst some improvements have been made to the environment, these were not undertaken within the agreed timescales and were still being completed during this inspection. This included improvements to the laundry and the refurbishment of the ground floor bedroom and ensuite. This should have been completed by June 2005 and was still in progress during the inspection. Residents are assured that The Gables is no longer used as a day care facility by other residents within the organisation, in response to a requirement from the last inspection, ensuring privacy in their home. Residents can be assured that the staff have available to them guidance on the protection of vulnerable adults from the local placing authorities. Residents have available to them a contract which they have signed as read by care staff. However, this was not in an accessible format. What they could do better: The home has failed to demonstrate compliance with six of the requirements from the last inspection. The Commission for Social Care Inspection is taking this seriously and is taking the first stages of enforcement action. From this visit there are a number of requirements that the home must address to ensure the safety of the residents and the staff. It was evident that the home has not been managed appropriately for the last two years. This has had an effect on the practices in the home, on record keeping including the reviewing of care plans and other related documentation. Residents would benefit from plans of care in place which clearly describes how they should be supported, including supporting them with their challenging behaviour detailing the strategies that staff undertake. Record-keeping relating to the support must be more comprehensive, for example as per the Department of Health’s guidelines on using restraint, giving clear guidance on what is acceptable and what is not acceptable. Residents must be assured that staff are competent and knowledgeable to support them both in dealing with the levels of challenging behaviour and meeting the care needs of the individuals living in the home. Residents would benefit from having support from other professionals to support the staff in providing holistic plans of care and agreeing the strategies in place. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 7 Residents must be assured that competent staff are supporting them in the event of a fire and that the fire fighting equipment is in good order. Residents must be able to get out of the building safely in the event of a fire. Residents would benefit from having a refurbishment plan for the home and where residents are restricted access that there is documentation supporting the decision process in the form of a risk assessment. Residents would benefit from having a doorbell installed to ensure their privacy when sitting in the lounge, as the only way for a visitor to let individuals know they are waiting to enter is to knock on the lounge window. Residents must be supported by competent staff who have undergone a thorough recruitment process offering them further protection. Where residents are at risk the home must ensure that there are safeguards in place to protect them from harm, including activating the protection of vulnerable adults policy. The home must be able to demonstrate that they can meet the care needs of the residents individually and collectively. Where one resident is causing harm to others the placement must be reviewed by the placing authority to ensure that it continues to meet the care needs of the individual without compromising the care of the other residents living in the home. Residents would benefit from a review of the staffing levels to ensure that they are meeting their individual and collective care needs. Residents would benefit from having information available to them so that they can fully understand and have more involvement in the running of their home. Residents must be safeguarded by the safe administration and recording of their prescribed medication and having competent staff involved in this process. 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 Gables DS0000003366.V250657.R02.S.doc Version 5.0 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 The Gables DS0000003366.V250657.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Whilst there is information in place to enable new residents to make a decision to move to the home, this requires expanding. The home has failed to demonstrate that it can meet the assessed and changing care needs of the residents. EVIDENCE: The home has introduced a statement of purpose and a service user guide. However, this requires some fine tuning to clearly describe the service provided at The Gables, for example the actual daily staffing of the home, the actual qualifications of the staff, including core training to enable them to support the individuals living in the home, and more detailed information on the review process of care plans. The statement of purpose includes details on the admission process and that visits would be tailored to suit the individual to enable them to make a decision on whether to move to the home. This was in response to a recommendation from the last inspection. The home has full occupancy and many of the residents have been living in the home for a number of years. It was evident that the home would liaise with the placing authorities prior to making a decision for an individual to be admitted to the home. This would include a full care plan and an assessment being obtained from the placing social worker. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 10 It was evident that the home would complete an assessment of need prior to an individual moving to the home. Less evident was a re-assessment and review of residents’ changing needs. This is an outstanding requirement from July 2004 and enforcement action is being taken. Contracts were available for the six residents living in the home. These were available in a written format. Consideration should be taken for the contract and the service user guide to be made available in different formats to assist individuals understanding of the documentation. This could be made available in pictures, symbols or an audiotape version. There was no evidence suggesting that residents had copies of this documentation. Training records were inadequate and did not link with the assessed care needs of the residents. This will be discussed later in this report. Records did not give sufficient detail on how the home was meeting the care needs, including supporting individuals with their challenging behaviours. There were no records detailing restraint used, even though speaking with staff and evidence from the investigation that this was a daily occurrence for one or two of the residents. The home must document each occasion when residents are restrained, as detailed in the Department of Health’s guidance on restraint, and the plan of care should include what method of restraint is to be used and in what circumstances and agreed within the boundaries of a multiagency approach. There were concerns that some methods of supporting individuals with their challenging behaviour were no longer based on current good practice. These included the use of sanctions and timeout. There was no documentation to support the decision process or agreements involving a multi-agency approach or a record of when this was undertaken. Staff stated that residents often do not go out if they are unhappy and one person is taken to their bedroom for a period of 30 minutes to calm down. This is unacceptable and must be reviewed. The home must seek guidance from either a psychologist or the intensive support team to review each individual’s behaviour and how staff support them. It was noted that a social worker had stated in an assessment that seclusion could be used. The home does not have the facilities to offer this method of dealing with an individual’s behaviour and again this should only be used if agreed within a multi-agency approach, as this is not based on current good practice. The placing authority must review this individual to ensure the home is suitable. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 The home has failed to demonstrate that the plans of care for individuals reflect their assessed and changing needs and personal goals. Residents were not being fully involved in the planning of their care. There were limited examples that residents are involved in the day-to-day running of the home. The home has failed to demonstrate that residents are safeguarded within a risk assessment framework. EVIDENCE: There is an outstanding requirement for the registered person to ensure that actions to meet the residents’ care needs and their outcomes were fully documented and to ensure that all residents’ care plans are reviewed six monthly. This has been outstanding since July 2004, December 2004 and March 2005. The provider has reviewed three of the plans of care and still three remain outstanding. Enforcement action is being taken for these to be completed within a short timescale. Further failure could lead to prosecution. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 12 The three care plans that had been reviewed still do not clearly describe the care provision and resemble an assessment rather than a clear plan that staff can follow. As already mentioned, there is a lack of information for staff to follow to support the individuals when they exhibit challenging behaviour and when this escalates to a dangerous level where they can cause harm to themselves or others. From conversations with staff, and a statement from the acting manager, restraint is used on a daily basis. There were no individual records detailing when this was used. The Commission for Social Care Inspection investigated an anonymous complaint as part of this visit. The complaints related to a member of staff, who allegedly dragged one resident from another to reduce injury and harm. All but one staff stated that this practice was appropriate and did not see this as a form of abuse. Staff stated that whilst this was not the norm however, on occasions it would be appropriate for staff to drag residents should they be at harm. On the day in question the daily record lacked any substance to substantiate this complaint. Action must be taken by the home, as follows, to address the poor practices that are in place: 1) The home must improve the records to detail all incidents of challenging behaviour; strategies used to support the individual and the outcome. Guidelines were given to the home on restraint and record keeping. 2) The staff must receive additional training to include appropriate procedures to move an individual from one place to another to reduce harm. This must be by an accredited provider. All staff must attend training as part of the induction process and attend annual updates by an accredited trainer on supporting individuals that may challenge. 3) All forms of restraint or restrictions must be documented in the daily care plan and agreed within a multi-agency approach. 4) Where a resident is causing harm to another the home must instigate the protection of vulnerable adults procedure. The newly introduced care plans were similar in content for all three people and lacked any real person-centred approach pertinent to the individual. Reviews should provide evidence of what was discussed detailing any amendments to the plan, who contributed to the review and including the perspective of the individual resident, and the outcome. This was lacking for all care plans seen. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 13 From talking with staff the provider had completed the reviews and had removed the care documentation to enable this to happen leaving no guidance for staff to follow. This again is poor practice. There was little evidence that residents are actively involved in the running of the home. There were no resident meetings and documentation was not accessible in the form of policies and procedures or the statement of purpose. The provider completed staff recruitment and staff were not aware of any resident involvement. This is an outstanding recommendation for the home to explore how individuals can have more involvement and will therefore be considered at the next inspection. Residents were observed lounging and sleeping in the lounges and not involved in any of the household chores. A member of staff stated that occasionally residents assist in the kitchen but not on a regular basis. Risk assessments were in place but lacked the wide spectrum of activities that residents undertake. For example accessing the community, using the home’s transport or for behaviours that challenge. An individual living in the home has a condition where they will eat all sorts of objects (PICA). Whilst viewing the individual’s bedroom there were cleaning products and other objects available to them, which could be seen as a hazard. There was no risk assessment in place to protect the individual and to guide staff. Where risk assessments were in place these had not been formally reviewed. The Gables DS0000003366.V250657.R02.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): 11, 12, 13, 15, 17 Due to the poor record keeping it was difficult to fully determine the opportunities that residents were being offered or how the home was monitoring the plans of care relating to independence and personal skills or engagement in leisure activities. Residents are being offered a healthy diet. EVIDENCE: There was evidence from discussions with staff and two residents to demonstrate that opportunities were provided to enable residents to maintain and develop practical and personal skills. Less evident was documentation to support this, including how the home monitors each resident’s progress in terms of communication, social and independent living skills. Each resident had a daily activity timetable. It was noted that five of the residents receive day care through the organisation and one person attends a day centre independent of the home. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 15 Each timetable was different to reflect the different interests of the individual and included arts and crafts, cooking, visiting shops, attending the day centre at Bedrock and swimming to name a few. Two residents were supported to go swimming at a local sports centre with one member of staff on the first day of the inspection as per their plan of activities. There were no risk assessments in place to demonstrate that the staffing was adequate to meet the needs of the residents; one of the individuals was noted to have epilepsy. In the afternoon four residents were lounging in the lounge; this did not reflect the timetable they were meant to be following. Daily records did not include information on how the individuals spent their time in relation to these activities. Staff stated that as far as possible the plans are followed unless an individual is unhappy. There was no evidence of refusals in the daily records or that individuals were offered alternatives. A resident stated that they go to church on a weekly basis. Plans of care included contact details and statements to say that these must be maintained. However, it was not clear from the documentation how this was being monitored or who was responsible for keeping regular contact. In response to a requirement from the last inspection the home has reviewed the practice of other residents from the organisation using The Gables as part of a day activities programme. Staff stated that this has stopped and only one resident visits the home to complete gardening and their own carer supports them. A resident stated that they liked living at The Gables and staff were supportive. They enjoyed the food and confirmed that they had a choice and were offered a different meal if they did not like what was on offer. Menu planning was not fully discussed on this occasion. However, the menu being followed the week of the inspection demonstrated that residents were offered a varied and nutritious diet. The food cupboards were well stocked with a combination of convenience food and fresh vegetables. Staff stated that the home completes a weekly shop for bulk purchases in addition to daily shopping for smaller items for example vegetables, bread or milk. A resident stated that they assist with the shopping. The home was granted a Food Safety Award from the environmental health officer in August 2005. On this occasion there were areas in the kitchen that had not been satisfactorily cleaned and plinths were missing from the base of the units. This was addressed by day two of the inspection. Food was not labelled or dated in the fridge, sauces were stored in cupboards and not as per the manufacturer’s instructions and food was not within the “use by” date. Again these were all addressed by day two of the inspection. The Gables DS0000003366.V250657.R02.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): 18,19,20 There was limited evidence that the residents’ personal and health care needs were being met, due to the poor record keeping. The home was unable to demonstrate that competent staff, in the administration of medication safeguards the residents. EVIDENCE: Care plans that were in place detailed a personal care statement relating to bathing. Of the three care plans seen all were similar in their content. The inspector was concerned that all encouraged the use of a cup of salt in the bath to assist with “Napkin rash” and cleanliness. It is recommended that this practice be reviewed and a more personalised approach be adopted and the home to explore the true therapeutic value of one cup of salt to the bath water. It was noted that bathrooms were lockable and could be overridden in the event of an emergency. There was no record of personal care given to ascertain the frequency of how often individuals were being assisted or supported. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 17 Care documentation included visits to the specialists and health care professionals. However, these lacked sufficient information in some cases to determine the outcome, for example a routine eye test, but no outcome was reported. Residents were being reviewed by the consultant psychiatrist. The reviews lacked any depth of discussion on matters relating to the individual’s behaviour. A medication review record did not correspond with what was recorded on the medication record. This matter was discussed with the staff on duty to review with the appropriate professionals. A medication audit highlighted a number of serious concerns including the lack of staff signatures supporting the administration, the medication recording chart did not include all prescribed medications (pain relief and an angina spray for another) and instructions were not written in full. An immediate requirement was given to the home to respond within 24 hours. This was not completed and enforcement action is being considered. There was an outstanding requirement for the provider to send evidence of medication training of all staff within the last twelve months. The home failed to comply. Evidence at this inspection was that only one person was completing a distant learning pack on medication, two staff stated that they had been shown by the manager but no formal training had been offered. Enforcement action is being considered. A note on the medication cupboard stated that “medication should not be dispensed six hours prior to administration and only if you are over the age of 18 years as you are deemed competent” implying that age alone would mean you are competent. This was removed at the time of the inspection. The inspectors consulted with staff about a complaint relating to the forcing of medication. Whilst staff were aware that residents should not be forced it was evident that the medication was concealed in food. This practice must be reviewed with the GP and the pharmacist and clearly documented in the plan of care, evidencing a multi-agency approach to the decision process. Another resident’s medication was broken into a more manageable size; again this must be reviewed and discussed with the dispensing pharmacist and clearly documented in the plan of care. Where residents are frequently refusing medication this must be discussed with the prescribing doctor and the psychiatrist. There was evidence in care records documenting the refusal of medication. This is good practice in that there was a clear record enabling staff to review with the appropriate professionals. The standard relating to death and dying was not discussed on this occasion. This will be a focus for the next inspection. The Gables DS0000003366.V250657.R02.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 Residents have available to them a complaints procedure. However it was evident that staff lacked confidence in using the complaints procedure. Residents would benefit from staff having a more comprehensive induction on abuse training. EVIDENCE: The home has a complaints policy and this is contained within the statement of purpose. There was no record of a complaint in the home’s complaint book since the last inspection. The Commission for Social Care Inspection has received three complaints relating to the care of the residents at The Gables. These were made anonymously. A Protection of Vulnerable Adults Strategy was called and it was decided that the Commission for Social Care Inspection would conduct the investigation. The complaints were as follows: 1) A member of staff allegedly dragged one of the residents across the patio by their ankles. The provider has taken appropriate action with this member of staff safeguarding the residents pending a full investigation. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 19 2) A resident was forced to take their medication. Medication for one person is hidden in food. (See the Standard relating to personal and health care). 3) Staff are being left in charge of the home when they are under the age of 21 years of age (see standard relating to staffing). 4) Staff feel intimidated by the acting manager. (See the standard relating to management). A member of staff stated that abuse is discussed as part of the induction process. Three staff stated that they would have no hesitation to report abuse. One member of staff stated that they had attended training with the local council on protection of vulnerable adults. There was no evidence of this in training records. Records confirmed that the induction covers a questionnaire on abuse. One member of staff’s completed questionnaire lacked in depth answers to demonstrate a full understanding of abuse and what to do in the event of a suspicion. However this person had received a certificate. This causes concern on the validity and the effectiveness of the training that is delivered to the staff working across the organisation by the provider. The home has a policy on abuse and local joint policies and guidance between South Gloucestershire Council and the local Police Authority was displayed on the notice board. The home has a policy on restraint. This requires updating to ensure that it reflects current good practice. The Department of Health Guidelines on restraint was given to the home to assist in this process. Staff were not following the home’s policy, as there were no clear records detailing when restraint was used as per the policy; staff stated that restraint is used on a daily basis. Training for supporting individuals that challenge will be discussed under training. Finances were not checked on this occasion. Therefore a recommendation is carried from the last inspection for the home to consider how individuals can have more control of their personal finances within a risk assessment framework. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Residents would benefit from a refurbishment plan and continual maintenance of The Gables. The provider has failed to demonstrate that they can meet the time scales for compliance to requirements from the last inspection. Residents would benefit from routine cleaning being completed on a regular basis. EVIDENCE: The Gables is a detached six-bedroom property in keeping with the local neighbourhood. There are shops and local amenities within walking distance. There was some evidence of renovation to the premises during the inspection. One bedroom was being completely refurbished including the ensuite facilities, new laundry facilities were being developed in one of the outbuildings and staff were reorganising the small conservatory to the rear of the property into a quiet room. These were in response to requirements from the inspection in March 2005. However the provider was requested to send in a refurbishment plan, detailing timescales of the above works, by the 30th June 2005. This was an outstanding requirement from the inspection in December 2004. This was not received and must be sent to the Commission for Social Care Inspection. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 21 Areas noted during this inspection include: 1) Communal areas require redecoration and new flooring: consideration should be taken to make these more homely and comfortable. The latter being within a risk assessment framework, acknowledging the different personalities and the levels of challenging behaviour. 2) The soft furnishings in the smaller lounge require replacement. 3) It has been recommended that the fluorescent lighting in the smaller lounge be replaced with domestic lighting. This is outstanding from the previous inspection. 4) To ensure that the tiling behind the cooker goes to the floor for ease of cleaning. An opportunity was taken to view all bedrooms. These were different in shape and size and decorated to reflect the different tastes of the individual. However, there were concerns raised that a significant number of wardrobes and bedroom doors were locked and residents did not possess a key to open them and some had minimal furniture which did not meet the National Minimum Standards. There was no documentation supporting the decision process in the form of a risk assessment for these infringements of their rights. This practice must be reviewed within a risk assessment framework. Decoration in one of the bedrooms was child-like. When discussed with staff there was no evidence that the individual had chosen the decor and staff felt it was acceptable even though this person is an adult. Some of the fire doors did not shut securely. The home must consult with the fire officer to ensure that all doors are adequate to withstand fire, offering the individuals living in the home protection. Access to the building is via the front door. There was no doorbell and the only way that staff’s attention could be gained by visitors was by knocking the window of the lounge, compromising the privacy of the residents. In addition, to leave the building staff had to use a key code. There are risks that in the event of a fire this could compromise the safety of the residents and the staff. The home must consult with the fire brigade regarding the front door being fitted with an automatic opener on the sounding of the fire alarm. There was no documentation supporting the locking of the front door. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 22 On the first day of the inspection the home had a strong odour and areas in the home were not clean, including the kitchen and the skirting boards throughout the home. There was a cleaning schedule in place but this was evidently not being followed. An immediate requirement was left with the home for this to be addressed. The inspector would like to acknowledge the commitment of the staff in ensuring that this was addressed. All areas seen on day two had been cleaned to a satisfactory standard. Other areas that the home had addressed by day two were the installation of the missing plinths to the kitchen units and replacement of a worn carpet on the stairs in response to an immediate requirement. Shared space consists of a lounge/dining room to the front of the house leading to a small conservatory and a second smaller lounge. These require redecoration and consideration to making them more homely for the occupants. Staff stated that the outbuildings are being reviewed in respect of their use and one was being changed from a storage area to house the laundry and another was being demolished and the third was a snoozelen for the use of the residents. Three staff had completed a distant learning pack in Infection Control in 2003. It was a requirement for staff to have further training in infection control. From talking with staff and viewing training records this had not been undertaken since the last inspection. Staff stated that gloves and aprons are provided. These were sited in the bathrooms and in the kitchen area. Bathroom areas were clean and in all but one area contained soap, hand towels and toilet rolls. Staff addressed this on the day of the inspection. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 36 Staff, whilst dedicated to their roles as carers, lack knowledge and insight into behaviours that challenge and the care needs of the residents. The home has failed to demonstrate that staff are supported in their roles and have clear lines of accountability and are aware of the legislation that guides them in their day-to-day roles as carers. EVIDENCE: The home must be staffed to meet the assessed care needs of the residents and the statement of purpose. The statement of purpose did not detail the daily staffing. Staff on duty stated that there was always three staff working in the home during the day and from 5pm there were two, with one member of staff providing a waking night cover. This was confirmed on the duty rota for the last two months. Due to the behaviours that challenge the home is required to review the staffing levels in the home to ensure that they are meeting the needs/safety of the residents and the safety of the staff. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 24 It is evident that when only two staff are in the home this limits opportunities for the residents. Due to the poor record keeping it was difficult to determine when the incidents of aggression were occurring. During the day staff stated that some of the residents are out at day care. However, on the day of the inspection four people were meant to be engaged in day care and were seen lounging in the lounges. Training records were incomplete with no evidence of recent training in the last twelve months for three of the four files seen. Staff stated that they complete an annual course in non-physical and psychological intervention; one member of staff had worked in the home for five months prior to receiving this course; there was no current certificate on file for any of the staff employed in the home; the acting manager’s certificate was dated 2003. The provider must ensure that staff complete this within their induction period and annually to ensure the safety of the residents and the staff. Five staff records relating to their employment were examined. Three staff members were working in the home without undergoing a criminal record bureau check completed by the provider; two people only had one reference and another had two references but not from the individual’s last employer. One person had no proof of identification. This does not meet with the legislation in ensuring the safety of the individuals living in The Gables. Three staff questioned directly about who provides the waking night cover in the home and observation of the duty rota demonstrated that all staff are over the age of 21 years of age. Staff were aware of this standard and one member of staff stated that they were not permitted to work on their own, as they were under 21 years of age. The inspector was concerned that a work placement (volunteer) had been organised for a minor and another member of staff was 16 when she commenced employment in the home. This must be reviewed in light of the levels of challenging behaviour. There was no criminal record check for the volunteer nor references or an application. Volunteers must have the same rigorous checks as a paid member of staff. There was no evidence of a staff meeting since December 2004 and due to the absence of the person in charge the inspectors had no access to supervision records. A member of staff stated that the manager is supportive but could not recollect any formal supervision sessions. Staff were positive about their roles and stated that they enjoyed working in the home. All staff were helpful during the inspection process. There were concerns raised about their awareness of the different needs of the residents. For example, two staff were observed debating whether an individual was epileptic, even though the individual was on anti-convulsants for the control of epilepsy and in fact had had a seizure within the last 24 months. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 25 Another person stated that it was part of a resident’s personality to smear faeces on a regular basis and this person was encouraged to go to their room to complete the act. This did not demonstrate to the inspector a clear understanding of the individual or the reasons why, and finding other appropriate ways for the individual to express their anxieties and fears. Staff stated that this behaviour has increased recently. There was no evidence of the home liaising with the psychiatrist or other behavioural specialists. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42 Residents do not benefit from a well-managed home which gives clear directions and provides a systematic review of the quality of the care provided. The home has failed to demonstrate it is a safe place to live and attention must be placed on ensuring the residents are safe and supported by competent staff in the event of a fire. EVIDENCE: The home has been without a registered manager for the last twelve months. An application was submitted and the individual was refused registration. It was evident from this inspection that this home has not been managed to a satisfactory standard. The number of requirements that range across all the standards evidences this. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 27 The home has completed an investigation relating to the complaints and all staff consulted described the acting manager as a professional person, someone they could look up to and that members of the team respected her. Staff working during the two-day inspection echoed this. One person said that she was well liked but her practice was sloppy. This was interpreted as that she had good relationships with residents but did not record information or delegate to staff. One staff member stated that it was felt that there was not enough support from the providers when managers take up post. In conclusion, whilst it was evident that the acting manager was well liked, she did not have the skills, the competence or the support to manage The Gables. Discussion with the provider on the second day of the inspection highlighted these issues and the importance of providing The Gables with management support, as an interim until a person has been recruited to the post of manager. It was evident that the home lacked clear direction on the management of aggression and that staff felt it difficult to deal with one of the individuals. However there was no consultation evident from other professionals in gaining advice and support for the individual or the staff. From reading the range of records in the home it was evident that since 2003 the home has not fully reviewed the documentation in the home including care information and staff records. Training records were incomplete. Staff were unaware of the home’s statement of purpose and were unable to locate the policies and procedures. The inspector located these documents. There were two sets of policies and it was not clear that one had been updated and the other was in fact the old copy. The office has a payphone for the use of all calls. Staff were seen having a professional conversation and having to put in 50p for the use. Staff stated that a budget is available for this. There were concerns expressed about whether this is professional, when the caller can hear staff using a pay phone. The home must review the use of the pay phone for business use and to enable the residents access to a phone. A full tour of the building was conducted and there were issues relating to the safety of individuals including a worn stair, the general cleanliness of the home and storage of chemicals hazardous to health. Whilst these were addressed there is still outstanding the risk assessment relating to the storage of chemicals hazardous to health. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 28 Fire records were seen. There were gaps in the training of staff and staff participation in fire drills. There was only a record of annual training and not periodic updates as described by the fire officer (six monthly for day staff and three monthly for staff working at night). There was no record for two staff of attending any training since they commenced in employment. The last fire drill was in May 2005 and previously January 2005. Three staff had not participated in a drill. All staff must attend a drill once in a six-month period. An immediate requirement was left with the home to ensure that all staff attend a drill within the next seven days and all staff attend fire training within one month. A fire risk assessment was in place and seen at the last inspection, however this had not been reviewed since 2003. Checks on the fire equipment had not been completed since August 2005 and there were gaps throughout the year with the fire equipment not being checked for a period between March to July 2005. An immediate requirement was made for the home to address this by the second day of the inspection. The home had not responded and enforcement action is being considered. As mentioned in this report, under the environmental standards the home must review the keypad on the front door and ensure there is documentation in place confirming the decision process for the locking of the front door, which is kept under review. Regulation 37 notices were discussed with the staff on duty. It was evident that the home was not informing the Commission for Social Care Inspection of incidents that affect the wellbeing of the individuals living at The Gables. An immediate requirement was made and this was to include all incidents where restraint is used to enable the CSCI to monitor these more closely. The home has completed a quality assurance questionnaire for residents. The last one was September 2004. There was no evidence of a business plan for the home. This was a recommendation from the previous inspection for the home to develop a business plan based upon systematic planning action and review of the services and the facilities provided to the residents. In the absence of the acting manager and the provider standard 43 was not discussed relating to the financial viability of the home. There were no concerns raised during this inspection that the home is not financially viable; staff stated that the residents have sufficient food and amenities. This will be explored more at the next inspection. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 29 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 2 3 2 3 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 2 2 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 2 3 2 X 2 LIFESTYLES Standard No Score 11 2 12 3 13 2 14 2 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 2 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Gables Score 2 2 2 x Standard No 37 38 39 40 41 42 43 Score 1 2 2 2 2 2 X DS0000003366.V250657.R02.S.doc Version 5.0 Page 30 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 Regulation 4 Sch 1 Timescale for action The registered person is required 14/11/05 to amend and update the Statement of Purpose to include all the details listed in the Schedule 1 of the Care Homes Regulations. A copy to be sent to the Commission for Social Care Inspection. (Outstanding 28.4.04) The registered person must 17/11/05 ensure that all actions to meet the service users’ needs and their outcomes are fully recorded. (Outstanding 2.12.04) The registered person must ensure that all service users’ plans are appropriately reviewed. Reviews should be thorough and detail any progress made, or goals achieved by the person, changes in the person’s needs their circumstances and in their lives. Reviews should demonstrate aspects and issues in the plans discussed with the service user at review, who contributed to the review, the DS0000003366.V250657.R02.S.doc Requirement 2 14,15 3 12 (2) 14,15 17/11/05 The Gables Version 5.0 Page 31 4 5 6 outcome of the review and amendments such as changes needed to support and services provided. (Outstanding since 28/7/04) 13(2) The registered provider is 17/11/05 18(1)(c)(i) required to supply the CSCI with full details of staff training in the administration and control of medication provided during the last twelve months. (Outstanding since 30/6/05) 23 2(b) The Commission must receive 14/11/05 detailed plans including timescales for completion of the work to be carried out to the home’s environment as detailed in standard 24 of the report dated March 2005. (Outstanding since 30/6/05) 23(2)(b) The registered person is required 14/12/05 to develop and implement a quality assurance system to measure audit and improve the quality of the services, care and support provided to the home. (Outstanding since 1/6/05) 7 8 13(6), 18(1)(c) 13(6), 18(1)(c) 9 10 13(6) 17 2 Sch3.3q 13(6),37 Staff to have training on the Protection of Vulnerable Adults from an external provider. The registered person to provide evidence of staff attendance in training on the use of restraint and the management of aggression. Staff must undertake this training as part of their induction within six weeks. The home must review the policy on restraint to ensure compliance to current guidelines. All restraint used in the home must be recorded in the plan of care agreed within a multiagency approach and recorded DS0000003366.V250657.R02.S.doc 14/01/06 21/10/05 14/11/05 14/11/05 The Gables Version 5.0 Page 32 11 37, 13 (6) 12 YA41 15 (1) 13 13(6) 14 37 15 18(1)(a) 16 16 (2) (c) 17 13 (4) (a) (b) (c) as per the Department of Health’s guidelines. A regulation 37 notice to be sent to the Commission for Social Care Inspection of all incidents where restraint is used or where service users are hurt. Care plans to clearly describe the levels of challenging behaviour and individual responses for staff to follow, which have been agreed within a multi-agency approach for each individual in the home. Where a service user is causing harm to others a protection of vulnerable adults referral must be made (with immediate affect) and a reassessment of their needs to ensure the home is appropriate by the placing authority. All incidents that affect the wellbeing of the individuals to be reported to the Commission for Social Care Inspection without delay including all incidents where restraint is used. The home must review the staffing to ensure that they can meet the assessed care needs of the residents (social, communication, emotional, personal, health and psychological) ensuring the safety of all the residents collectively and individuality. Residents must be provided with furniture as per the minimum standard unless a risk assessment demonstrates otherwise, which is kept under review. All risks must be clearly documented including COSSH, social activities, use of minibus, accessing community, or any restriction imposed by the home DS0000003366.V250657.R02.S.doc 14/11/05 14/10/05 14/11/05 14/10/05 14/11/05 14/01/06 14/01/06 The Gables Version 5.0 Page 33 18 23 4(b) 17 2 Sch3.3 q 19 20 13(4)(c), 23(4)(a) 23(4)(iv) (v) 23(4)(e) 23(4)(d) 12(4)(a) 13 (2) 13 (2) 21 22 23 24 25 26 13 (2) 27 28 The Gables 13 (2) 23 (2) (b) for all residents detailing strategies for staff to follow to minimise the risks whilst encouraging independence of the individual. Review the use of the key code on the front door taking advice from the fire officer. Consideration to be taken to install an automatic door opener in the event of a fire. A risk assessment must be in place demonstrating the decision process of the locking of the front door. The home must keep the fire risk assessment under review. The home must ensure that the fire checks are completed in accordance with the fire officer’s advice. All staff to attend a fire drill every six months. All staff must attend training every 3 months for night staff and six monthly for day staff. Install a doorbell to the front door unless a risk assessment demonstrates otherwise. All prescribed medication to be documented on the medication record. Ensure that the member of staff administering the medication signs the medication record of administration. Medication must not be given covertly or crushed or changed from its original form unless there is clear documentation supporting this and only within a multi-agency agreement. This must be kept under review. Medication record to include clear information on when to give, the amount and frequency. For the lounge areas of the home to be decorated and the DS0000003366.V250657.R02.S.doc 14/11/05 14/11/05 14/10/05 21/10/05 17/11/05 17/11/05 17/11/05 17/11/05 21/12/05 17/11/05 17/12/05 Page 34 Version 5.0 29 17(2) Sch 4.6 30 31 17(2) Sch 4.6 18 (1) (c) sofa in the small lounge to be replaced. For staff to only commence in post once a POVA/criminal record check has been undertaken. Staff that do not have a CRB check this to be requested within seven days and evidence provided that this has been done. For staff to only commence in post once two references have been received. For the home to develop a training plan for all staff to include mental health, epilepsy, ongoing health and safety training. Training to be delivered by a competent person. A copy to be sent to the CSCI. 17/10/05 17/10/05 17/10/05 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 Good Practice Recommendations The service user’s guide and the terms of conditions should be made available in an accessible format including where relevant photographs, pictures and symbols and/or available in an audio format. The manager should consider meaningful ways to enable the residents to extend their influence in the running of the home including regular meetings. The manager should consider ways to enable residents to have more control over their personal finances within the management of risk (not re-assessed on this occasion) The fluorescent light in the lounge should be replaced with a domestic style light. Review the practice of putting salt into individuals’ baths. Review with the individual’s doctor the use of vitamins to ensure that they are compatible with prescribed DS0000003366.V250657.R02.S.doc Version 5.0 Page 35 2 3 4 5 6 The Gables 7 8 9 10 medication and the health of the individual. For the staff to have regular team meetings. For staff to have formal supervision at least six times per year. It is preferable that one of the staff references is that of their last employer. For the home to ensure that the cleaning schedule is completed and staff to sign to enable this to be monitored. The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 36 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 The Gables DS0000003366.V250657.R02.S.doc Version 5.0 Page 37 - 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!