Inspection on 02/04/09 for Brain Injury Services, 51 The Drive

This inspection was carried out on 2nd April 2009.

CQC 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 CQC judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brain Injury Services, 51 The... 03/04/07

Brain Injury Services, 51 The... 10/02/06

Brain Injury Services, 51 The... 19/09/05

Brain Injury Services, 51 The... 03/12/04

Brain Injury Services, 51 The... 10/06/04

Brain Injury Services, 51 The... 18/03/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Brain Injury Services, 51 The Drive Northampton Northants NN1 4SH Lead Inspector Ansuya Chudasama Unannounced Inspection 2nd April 2009 11:40 Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brain Injury Services, 51 The Drive Address Northampton Northants NN1 4SH 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) 01604 233482 01604 638176 WWW.partnershipsincare.co.uk Partnerships In Care Ltd Vacant Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All service users will have an acquired Brain Injury. Age Range 27 - 60 Years of age Date of last inspection 3rd April 2007 Brief Description of the Service: 51 The Drive is a Care Home providing personal care for 3 service users with acquired brain injury. The home is owned by Partnership in Care Limited and is adjacent to another home owned by the same company. The home is located in a suburb of Northampton close to a local shopping centre and park and easily accessible by public transport. The home was opened in January 1994 and consists of a large semi-detached house with front and rear gardens. Single room accommodation without en suite facilities is provided for all service users. The home is not suitable for people who have mobility problems because the home does not have a lift. The current fees are £2,122.38 per week; additional charges are made for hairdressing, toiletries, newspapers, magazines and gym membership. Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home has 1star rating and this means that the people using the service receive an adequate service. This inspection was carried out in accordance with the Care Quality Commission (CQC) policy and methodologies which require review of key standards for the provision of a care home for younger adults that takes account of the people’s views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit. The report refers to ‘we’ this is because the report is written on behalf of the commission. We last inspected this service on the 11/4/07. This key inspection was carried out on the 2/04/09. The staff in the home and a manager from a sister home staff also helped out with the inspection process. During this inspection we tracked the care of two people who use this service. This involved reading their care records and also talking to them wherever possible to obtain their views on the service. Documentation relating to staff recruitment, training and supervision, medication administration, complaints and health and safety were also examined. We had the opportunity to talk to most of the staff who were on duty and a tour of the home was also conducted. The home had not sent us their Annual quality assurance assessment (AQAA) when we asked for this information. We received surveys from the home when we asked for them. What the service does well: The home is clean and pleasantly decorated. One person told us that ‘it is like a home’. Another person said ‘it is a lovely place to live in’ and ‘I talk to the Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 6 people and staff’. They all told us that the food is very nice and they can choose what they like to eat. We were also told that ‘the staff are very nice and I get on well with all the staff’. They told us that they like their bedrooms and they chose the colours of their rooms. The people have bedrooms that meet their individual needs. The people go out on activities and holidays with staff. They were observed talking to staff and telling them what they wanted to do. The home has house meetings where people have an opportunity to take part in making decisions. The staff enjoy working at the home and it was said ‘I do like it here’. The staff work very hard to meet the needs of the people They attend lots of training to help them meet the people’s needs. They were observed talking and listening to the people and offering advice in a positive manner. They say they get good support from the staff team. What has improved since the last inspection? What they could do better: The home should ensure all staff receives at least 6 supervisions per year to find out how they are working in the home. Review the statement of purpose so the information is up to date for perspective people who want to come and live at the home. The care plans needs to be reviewed and this should be done on a six monthly basis or as and when changes occur with the people. This is to ensure that the information about the people is kept up to date to meet their needs. Management needs to provide clear leadership and clear communication systems in the home, as this will improve staff morale, which will result in an enthusiastic workforce that works positively with the people to improve their quality of life. Undertake the people’s surveys and regulation 26 monitoring visits to find out how the home is meeting the needs of the people and the people who work for them. Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 7 Ensure that the paperwork in the office is better managed. Provide refresher training for the fire marshals so they are up to date with the information that they need to know. The home must complete the AQAA and send us this information. This is important because it helps us plan our future regulation of your service and if they don’t do this, they will be committing an offence. Replace the carpet in one of the people’s bedrooms to avoid any accidents happening in the room. Ensure that the medication records are properly completed to minimise the risk of any accidents from occurring. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Needs assessments and visits to the home are carried out for all the people admitted to the home to ensure that their needs will be met. EVIDENCE: The home has a Statement of Purpose and this document needs to be reviewed to ensure that the right information about the Quality Care Commission (QCQ) is recorded. The information about the complaints procedure needs to be recorded with the telephone numbers of the relevant agencies. The information about the previous manager is still recorded on the document. The new manager’s details needs to be updated on the document and needs to be individualised to the home. The home has not admitted any new people for a long time. The care records read showed that the people had visited the home with their families. The home had also carried out needs assessment for these people. The people say ‘that this is a lovely place to live in’ and ‘I talk to the people and staff’. Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 10 All the people in the home have contracts and the people had signed these and the manager of the home had also explained and signed the document. Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9, People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people have care planning documents and these needed reviewing to ensure that the staff have up to date information needed to meet the people’s needs. EVIDENCE: We looked at two people’s care plan in detail and discussed the people’s care needs with staff on duty. The staff had very good understanding of the care needs of all the people in the home. We were told that the care plans were being reviewed on a regular basis. This was observed but this information was not being updated in the main care Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 12 plans. For example one plan seen was up dated in 30/1/08. Some of the information read in the plans needed expanding to explain how some behaviour’s were being managed. This was discussed with the manager from a sister home and it was said that all the care plans would be reviewed with the people. Risk assessments are in place that enables the people to take risks as part of an independent lifestyle. The information on risk needed to be in the hazard section and information on hazards needed to be in the risk section. Discussion with the manager from the sister showed that the risk assessments were going to be reviewed with the people and these would be developed in a format that the people would understand. This was very positive. The care plans were stored in locked filing cabinets in the office. During the inspection we saw staff talking to people in a friendly and supportive way. They supported people to make decisions and choices for themselves. Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: 12,13,14,15,16,17 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The routines and activities of the home are planned in a way, which meets the choices and wishes of the people. EVIDENCE: The people had their individual programmes for activities they undertook. The records looked at showed that the people go to the local park, shops, to town, the cinema, horse riding and work experience centre. They also go on holiday and we were told that the holiday was booked for this summer. A risk assessment needs to be undertaken for this activity. There were photographs seen of the people when they had been on activities and holidays. One person Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 14 told us that they enjoyed going out to have coffee and staff supported the person to do this on a regular basis Some of the people in the home maintain contact with their families/friends. We were told that the staff escorted one person to visit their family, which was far. The lounge area provided a homely atmosphere where the people relax and enjoy a quite moment watching the TV, read a book or play cards. We had sat with staff and one of the people living in the home when they were having their lunch. This was eaten in a relaxed atmosphere with good conversation and banter taking place between the staff and the person. . We were told by the person that they choose what they wanted to eat and helped staff with laying and clearing the table, and they helped with washing up. This was observed at lunchtime. The meals recorded were healthy and staff had good understanding of the people’s likes and dislikes of food. This was also recorded in the people’s files. The people told us that they liked the food and they get on well with all the staff. This was observed on the day of the inspection. They said that they chose the colour of their bedroom, and like living at the home. Each person’s bedroom seen showed that the home supported the people to pursue their chosen hobbies. The people were supported to clean their rooms and do their laundry work. We observed the daily routines of the people and they told us that the staff helped them to do things to make them more independent. The garden was lovely and we were told that all the people enjoyed sitting in the garden. New furniture that met the needs of the people was needed for the garden. The home has house meetings where people have an opportunity to take part in making decisions. The last meeting was held in February 09. We were told that the people in the home would like a digital box so they could watch a wider variety of programmes. Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people’s personal and health care needs are met by the home. EVIDENCE: The care plans we saw clearly set out peoples support needs and preferences in receiving personal care. The staff we spoke to were very knowledgeable about the people they care for. We observed staff interaction and noticed that they talked to people in a respectful manner and were careful to preserve their dignity. There is evidence in the care files that people are offered support for their physical and emotional health needs. There are records of general practitioner, clinical psychologist and hospital appointments, and people have access to the district nurse, opticians, dentists, and other health care professionals. The Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 16 people told us that if they did not feel well, they would tell the staff. This was observed on the day of the inspection when one person in the home was not feeling well and staff were very kind and supported and monitored the person. The staff that gave out medication had received this accredited training. The medication records looked at showed that there were gaps in the record where staff had not signed to say that the person had been given their medication. This was also recorded in the communication book informing staff that they needed to sign the medication sheets. The staff also needed to write down when medication was stopped and started. The people had signed the consent form for staff to give out their medication. The staff had good understanding of the medication the people took. One person’s file looked at had information about their wishes when they died. This was well recorded. Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff have good understanding of the people’s behaviours to ensure they are protected from any abuse. EVIDENCE: The staff spoken to informed us that they had completed the safe guarding of vulnerable adults procedures training. They had good understanding of this and understood the people’s behaviours to know if they were unhappy or not feeling well. The home had carried out risk assessments and put in support systems for the people when out in the community on their own. The people themselves were also capable of informing staff if they had any concerns. They told us that they would tell the manager or staff if they were not happy. The home had not received any complaint since the last inspection. No safe guarding referrals had been made to Social Services safe guarding team. The people’s finances inspected showed that this was managed well. Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is pleasantly decorated and provides a relaxing atmosphere for the people living at the home. EVIDENCE: A tour of the home showed that the place is clean and homely. The pictures and ornaments made by the people are displayed in the home. The main corridors of the home were light and airy. The peoples bedrooms seen are homely and comfortable and individualised to the person. All the people have single rooms. One of the people in the home told us that they had carpet that was fraying in parts of the room. They asked for the carpet to be replaced in Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 19 their room and had chosen what they wanted to put in their room. We were told that after three years this had still not happened. The person was very unhappy about this and this was observed on the day of the inspection. The communal rooms are pleasantly furnished to a high standard. The home has a pleasant garden and people like to sit outside. The people need garden furniture that is sturdy and meets their need. The dinning room chairs needed replacing as they were unsteady and we were told that these had been repaired recently. The kitchen was painted 4 months ago and looked bright and pleasant. The laundry room was clean and well organised. We were told that the lounge is going to be painted. The settees in the lounge were low and it was difficult to get out of the chair. We were told that the maintenance man was going to raise the chairs. The home has an office on the second. Two window needed repairing and the health and safety book seen showed that this task was repeated a number of times. Information read in the office stated that the organisation was considering putting a door in the dinning room so the people and staff can walk through to the sister home. The information read about the people in the two homes showed that this would have a detrimental effect on their well being. The staff spoken to also confirmed this. The two homes are at present registered as individual homes with the commission. The organisation would need to apply to the registration team before any changes can be made to the home. Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff have good understanding of the needs of the people however the staffing working rota needed reviewing to ensure there are adequate staff on duty to meet the needs of the people. EVIDENCE: The staff recruitment files were looked at in detail. Evidence showed that the home was obtaining all the relevant information required to safe guard the people in the home. Staff spoken to and records seen showed that not all the staff were receiving supervision on a regular basis. This is to monitor how staff are working in the home and to look at their training development needs. This needs to be recorded with the date this took place and not just the month and year. Evidence also showed that not all staff were getting appraisals. Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 21 The staff working rota showed that staff sometimes worked on their own. This also included people who are bank staff who do not work on a regular basis. We were told that the staff struggle when they work on their own. This is because they still have to work with the people, and do their daily chores such as cleaning, cooking, shopping, give out medication, and complete the records. We were also told that ‘some of the people can get aggressive in a split second and when you have no support this is extremely hard to deal with on your own and keeping other residents away from aggressive situations’. We also noted that sometimes staff worked long shifts to cover the working hours. This was because the staff wanted to provide continuity to the people. The home had a fulltime vacancy and this position was being interviewed. The working rota needs to be reviewed to ensure that there are adequate numbers of staff on duty to meet the needs of the people. All staff working in the home needs to have their names recorded on the working rota and this also includes the manager. This is so the people in the home know who is working each day. We were told because management hours were not recorded on the rota, the staff did not know when they were visiting the home. We were also not able to ascertain when management visited the home. We were told that ‘staff moral in the home was low’. This was noted at the inspection, and from survey questionnaires returned had comments such as ‘we feel abandoned’. We were told that the staff wanted to ’see a manager who listens to staff’ and it was said ‘this has not always happened’. The key worker programmes were not always being completed because staff were working on their own and support from management was not available. We observed that the role of the house coordinators included having to do extra duties, such as maintaining care plans, programmes, supervision, fire training, appointments, appraisals, and risk assessment. The staff working rota showed that these staff also at times worked on their own. This was observed on the day of the inspection. We were told that they received one day a month to complete their extra duties and they worked extra hours in their own time to get their work completed. Management needs to reassess the duties of the coordinators to find out if one day is adequate to undertake their extra duties. The staff in the home were not aware when staff were coming back from leave and when the acting manager had started to work at the home. We were also told that some staff did not feel part of the team. The staff enjoyed working at the home and it was said that they looked after the people’s needs well. They say that they have ‘worked hard to keep the place going and this was especially in the last six months. We were told that the home had not had a full staff meeting for a long time. We were also told Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 22 that more meetings were needed with management. The acting manager told us when we inspected the other sister home that they would start this. We were told that the training provided by staff from one of the sister home was not good. It was also said that the training given by one of the sister home was not appropriate to the home that they worked at. This was discussed with management and we were told that all the training provided for staff would be accredited. Staff also asked for training in behaviour modification, equal opportunities, sexual orientation, race, faith, medication, assertiveness, assessment writing and deprivation of liberty Act training. We were told that some staff wants to do NVQ training and have asked for this for a long time but this had not happened. New staff file looked at showed that the staff had an induction at the home and had completed the skills in care induction training. We were also told that new staff had to shadow an experienced member of staff until they were confident to work on their own. Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41,42 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run in the best interest of the people and management is aware of the areas where they need to make improvements to meet the needs of the people. EVIDENCE: The acting manager of the home was not present and we were told that they had recently been appointed to this position in January 09. We were informed that they managed this home and the sister home next door for three days a Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 24 week. The other two days a week they worked as a programme coordinator at another sister home. The acting manager found it difficult to switch from the two roles that they worked for the organisation. This did not give the person the opportunity to get to understand their role as the manager of the two homes. The acting manager was not given any induction when they were undertaking this new role. Discussion with the acting manager showed that they had good understanding of the areas that needed improving in the home. The staff spoken to at the inspection, anonymous concerns raised with CSCI and surveys received stated that ‘staff morale was low’ and they felt that they ‘have been abandoned’. It was also said ‘when management support is not available, staff biker’. Some staff spoken to asked for a team building day and this was discussed with the acting manager when we carried out an inspection at the sister home. We were told that they had already made a note of this. We were also told that the new acting manager was nice but it was said that this person did not spend much time at this home. They wanted a manager that was going to work full time and spend time in this some. We were told that the staff worked very hard but management do not recognise this and do not feel valued for all the hard work they do. Staff said that they all do ‘above’ their job to meet the people’s needs. We were also told that better communication and support from management was needed to help improve staff morale. We received a letter from the organisation to inform us that the Acting manager was successful in getting the permanent position to manage the two homes. We were told that management from another home would support the manager with undertaking this role. The staff were not able to find regulation 26 visit reports for the home. They were also unable to tell us if these visits were being carried out. The home had not carried out the people’s surveys, to get their views about living at the home. The home had not send us the AQAA when we asked for this information. It is important that you send us this document urgently. It is an offence under Regulation 24 and 43 of the Care Homes Regulations 2001 not to fill in and send to us the information we ask for in AQAA part 1 and 2 because if you do not send us this information you may be committing an offence under Section 31 (9) of the Care Standards Act 2000. We will consider taking enforcement action if we do not receive both parts of the AQAA The paperwork in the office needed to be better managed because information was difficult to find. We were informed that when the administrator was off on maternity leave, the administration side of the work had lapsed. We are aware that since the administrator has been back from leave, they have to work at Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 25 the other sister home. However it would be a good idea for this person to spend more time getting the filling up to date in the office in this home. The fire alarm system was being tested on a weekly basis. The emergency lighting was done on a monthly basis. We were told that fire drill practice was happening four times a year. Both the people and staff on duty were involved with this. A fire risk assessment was carried out on the 2/1/09. The staff had training on health and safety, infection control and food hygiene. Not all staff knew how to use the fire extinguishers. Records showed that five staff had done this training. The fire policies and procedures needed updating and fire zone panels were needed for the home. The fire marshals needed to have refresher training as they have not had this for a long time. We were told that not all staff had received in house fire training. All visitors to the home needs to write their name in the signing book. This is because when there is a fire, the book is used as a record to check and make sure these people are not still in the home. Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 3 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 2 2 2 X 2 2 x Version 5.2 Page 27 Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc 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 YA6 Regulation 15 Requirement Review the care plans with the people. This is to ensure that the information recorded is up to date so the staff can meet the people’s needs safely. Review the staff working rota to ensure the needs of the people are met. Provide a clear quality assurance system that is easy to understand on an annual basis. This is to find out how the needs of the people are being met. Management must complete the AQAA when asked for by the CQC. This is so that we are aware of how the home is managing the needs of the people and information that we need is obtained for monitoring purpose. All staff must receive in house fire training. This is to ensure that the people’s safety is maintained. Timescale for action 30/06/09 2 YA33 18 20/05/09 3 YA39 24 30/07/09 4 YA39 24 20/05/09 5 YA42 13 10/05/09 Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard YA1 YA13 YA24 YA36 YA39 Good Practice Recommendations Review the statement of purpose to ensure that the information about the home is up to date. Undertake a risk assessment for all the people going on holiday. Provide suitable furniture for the garden that meets the people’s needs. Provide supervision at least six times a year to monitor staff performance. Undertake regulation 26 visits on a monthly basis to monitor how the home is doing.. Reassess the role of the house coordinator to find out if one day is adequate to meet their duties Provide NVQ level 2/3 and other training as discussed in the report for staff Undertake a full team meeting so the staff know what is happening in the home. Provide refresher training for the fire marshals. Ensure that medication records are properly completed. 6 7 8 9 10 YA33 YA35 YA33 YA42 YA19 Brain Injury Services, 51 The Drive DS0000012718.V375061.R01.S.doc Version 5.2 Page 29 Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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