Inspection on 08/05/07 for Brook House

This inspection was carried out on 8th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brook House 01/12/08

Brook House 04/02/08

Brook House 03/05/06

Brook House 08/11/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Brook House and 58 Ash Grove Brook House and 58 Ash Grove Four Pools Evesham Worcs WR11 6XN Lead Inspector Sue Davies Key Unannounced Inspection 8th May 2007 10:00 Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Brook House and 58 Ash Grove Address Brook House and 58 Ash Grove Four Pools Evesham Worcs WR11 6XN 01386 765551 01386 429380 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) www.macintyrecharity.org MacIntyre Care vacant post Care Home 10 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (2) of places Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The care home is primarily for people with a learning disability but may also accommodate people with an additional physical disability. No more than eight residents will be accommodated at Brook House and no more than two at 58 Ash Grove. The lease in respect of Brook House and the Service Level Agreement in respect of 58 Ash Grove (both between Evesham and Pershore Housing Association and MacIntyre Care) will be amended as advised by the CSCI within one month of registration. 3rd May 2006 Date of last inspection Brief Description of the Service: Brook House and 58 Ash Grove provide residential care for up to ten adults with learning disabilities. There is accommodation for up to eight service users in Brook House and for two service users at 58 Ash Grove (next door) where service users are able to live more independently. Brook House and 58 Ash Grove are operated by MacIntyre Care who were registered on 1st November 2005 in respect of this service. Evesham, Pershore and District Mencap Society own Brook House and 58 Ash Grove is owned by Evesham and Pershore Housing Association. The stated purpose of the organisation is, ‘to be recommended and respected as the best provider of services for people with learning disabilities throughout the United Kingdom.’ The Responsible Individual is Mr William Mumford. There is no registered manager at present. Current fees for this service are £567.00 Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place during the days of 8th and 9th May 2007. The purpose of the inspection was to look at how the service is achieving good outcomes for the service users in key areas of the national minimum standards. The home is an established service, having been open since 1981. Time was spent preparing for the inspection by reading documentation, including previous inspection reports, notifications and the pre inspection questionnaire, A first visit was made during the early evening to introduce the inspector and spend time with the nine service users at home, the inspection continuing the following day. The manager and deputy was present on the first day of the inspection, and the inspector also met with 3 staff members, toured the building and looked at a range of documents and records. Some time was spent looking at changes to the service since the last inspection and meeting with the nine service users, who were all at home from late afternoon onwards and some for part of the daytime. The service users were at their day centres or college, or having a relaxing time either at home or going out locally following chosen activities. On the days of the visit there were two or three staff on duty who were supporting service users at home or accompanying them out. The time and assistance given by service users and staff during the inspection were appreciated. What the service does well: What has improved since the last inspection? The acting manager and a service user have written one service user plan in a person centred way to show how it should be done Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 6 A staff training programme has been introduced. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A community care assessment was seen on record for one current service user. Consideration is being given to seeking up to date community care assessments for service users. Information for prospective service users must include details about room size. EVIDENCE: One of the two service users’ files seen contained a community care assessment completed before the service user moved in. The acting manager is intending to request up to date assessments. All nine service users have lived here for many years, and significant changes in their needs mean it would be good practice to reappraise the service they each require (see also sections ‘Needs and Choices’ and ‘Personal and Health Care’). Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 9 A room significantly smaller than new build standards is still available to offer to prospective service users. Full information about the room size and its limitations must therefore be provided to any prospective service user who may be offered this room, and their personal space needs assessed, so that a realistic decision can be made about suitability. Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. While there has been work on some service user plans, there has not been enough progress in person centred planning since the previous inspection. Plans and risk assessments remain in need of significant improvement. Inappropriate attitudes seen in records and in practice must be responded to robustly so that service users can be confident this will not be tolerated. Service users need their personal information to be recorded more effectively in a service user plan and personal records. Staff need clear, consistent guidance and support on sound recording values and practice. Sustained effort is needed to promote effective person centred planning, so that service users can be supported and enabled to play a full part in making decisions about their own lives. Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 11 EVIDENCE: Service users cannot be confident their needs are reflected in their personal plan so that staff understand and support them effectively in the way they prefer. Plans seen needed to be recorded in a more systematic way and in greater detail, putting service users experience at the centre of making plans for their care and support, and in making their own decisions. The acting manager has worked with one service user to revise his plan in a person centred way as an example to staff how this should be done, but this still needs to be done on all the other plans. Some training in person centred planning has been provided but staff are unsure what is expected of them. Evidence from records shows staff are unclear how to support service users towards taking more responsibility for themselves, so that staff are doing this and making decisions for them. The records system both reflects and contributes to this confusion. Records are not well designed, so information about personal and health care needs is recorded in a number of ways and in different places. This means service users cannot be confident staff will have all the information they need to support them in a consistent way. Daily records need to be redesigned to contribute more effectively to a sound plan of care. Staff would benefit from training on handling and recording personal information. Service users have a right to expect their personal details will be treated with respect for confidentiality and their dignity, and to enhance their well being, but some recording practice falls short of this. An appointments diary alerts staff to appointments service users need to keep, but also contains the appointment letters pinned to the pages. These are private and should be stored in personal files. An openly available day-to-day staff communication book is intended for passing on essential information from shift to shift. Where staff need to be alerted to information that is both personal and confidential, this record should be used to signpost staff to service users’ personal care plans and daily records. However, it contains explicit and sometimes the only reference to healthcare matters for named service users, such as an occupational therapist’s recommendations, reference to medical details, the outcome of GP Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 12 visits, and progress of treatment. None of the instances had been linked to specific guidance and action in a service user plan. Not only does this disregard the values of dignity and respect but information which is not recorded more appropriately is therefore in danger of being subsequently overlooked, so that significant information about service users well-being could be lost. Opportunities for monitoring and planned progress may thus be missed and service users well-being could be compromised. Clear staff guidance is needed to make sure service users’ personal information is properly managed with respect for dignity and confidentiality. Where there are aspects of service users lives that may be risky for them they need staff to understand and support them to manage the risks well, so they can be as independent as possible. It is very important that there is a good system for assessing risk and keeping these assessments up to date. Risk assessments have not been reviewed and updated since 2005, despite evidence of significant changes. For example a placing authority review following a service user’s illness notes an altered road safety awareness, but the previous risk assessment regarding road safety skills is unchanged. This requirement from the previous inspection therefore remains outstanding. Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15, and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have things to do at home and out in the community that they enjoy, but it is not clear what planning goes into this or how much this involves service users themselves. Staffing levels are low and do not allow for much one to one time. There is scope to develop more community links. Family contact is supported and encouraged. More could be done to make sure meals and mealtimes are person centred. EVIDENCE: At the time of inspection most service users were out at regular day centre and college activities, older service users attending facilities more suited to their age and preferred pace of life. One service user was visiting family for a birthday celebration, and one was at home taking care of household chores. Later, service users spent time on activities around the house. Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 14 There is some evidence of real achievements service users are proud of, such as a certificate for completing a charity walk, and art and craft work displayed around the home. Photographs on display show service users enjoying themselves on outings, festive and holiday occasions spent together with each other, friends and families. However there is no clear evidence that service users interests, talents and preferences are explored individually with them, setting and achieving goals as a process of personal development. Some activities are listed in the appointments diary and day-to-day communication book. Service users’ personal files contain activity charts but these are not completed in a consistent way, and the format is neither person centred nor easy for service users to understand. Information recorded in the charts seen is limited and repetitive, suggesting a similarly unvaried lifestyle, for example one service user’s chart lists only ‘home’ for activities on Mondays, Saturdays and Sundays, and ‘Bungalow’ (an activity centre) for Tuesdays to Fridays, with nothing recorded for evenings. A small chart on the office notice board includes regular weekly activities such as rug making, craft, horticulture, swimming, walking and bowls, and attending the local Gateway Club. Such a chart could be the basis of a planning tool service users could use themselves, but needs to be in a more suitable location and in a format such as symbols or photographs, so that it is accessible to service users and easy for them to understand and use. Some service users told how they enjoy going to a music club, going out shopping or for a drink with staff, and for pub meals. The range of activities could be extended to encourage more outside interests and contact with the wider community, and needs to be considered with individual service users as part of the development of a person centred approach to planning. Current staffing levels are too low to provide many opportunities for one to one activity out of the home, and during the inspection service users at Brook House were seen spending time on solitary pursuits although better staffing ratios at no. 56 Ash Grove meant service users and staff were able to spend more one to one time together. Evidence on the day of inspection showed staffing levels can make it difficult for staff on duty to respond to spontaneous requests. For example one service user wanted to go for a regular walk after the evening meal but it was half an hour before a staff member was able to go, leading the service user to become very agitated while waiting. Contact with families is supported and encouraged. One service user proudly showed many photographs of time spent with a large family, another was planning a mother’s birthday present. Staff confirmed that most families are in Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 15 regular contact, visiting the home or inviting service users on trips out, away on holiday or to the family home. Meals at Brook House are freshly prepared and served by staff in the large kitchen. Although a more able service user described taking part in this, there was no clear record showing if there was a planned approach giving other service users opportunity or support to do so. Meals are planned at meetings with service users, but while some service users are able to communicate their wishes verbally it is not clear how service users with limited verbal skills participate in meals planning and choices. The menus seen provide limited information only, and although some brief details about the day’s main meal were on the wall in the dining room there is no easy read version so that service users know what is offered and can make informed choices. The record of food provided needs to show all meals in full detail including all alternatives provided. The approach to serving meals is largely staff led, and follows an institutional pattern. For example, during the inspection staff told service users the meal was ready and called them to the kitchen. They served up food there from pans they were cooked in directly onto service users plates as they stood waiting one by one. Service users were asked what they wanted, some but not all were encouraged to help themselves. They were offered the choice of eating at the kitchen table if they preferred, which some did, then took their plates to the kitchen or dining room table. One service user regularly chooses to eat alone in the conservatory. The two service users at no. 56 Ash Grove eat separately there although in practice one service user chooses to eat elsewhere. Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the home. To make sure consistent care is provided by all the staff team, records need to be person centred and to provide a full, clear, up to date and integrated account of service users personal and health care needs, showing personal care preferences and any action needed to promote good health and well being. This is a requirement from the previous inspection that still needs to be attended to. Staff say they are confused about what is good and poor practice, and there is evidence of inappropriate recording and care practice showing staff need more guidance. There are older service users at this home, with additional needs associated with ageing. They are supported by staff with patience and kindness, but staff have had no specific training to help them understand the ageing process and associated special support needs. There were some concerns about the management of medication so the pharmacy inspector has been asked to do a full inspection. EVIDENCE: Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 17 This inspection identified concerns about the quality of support service users are receiving for personal and health care. This has to do with both the quality of service user plans and records, and the support staff are given to implement sound values and practice. Service users cannot be confident that their needs will be met in the way they prefer, because records are poorly designed and incomplete, and staff practice is variable in the absence of consistent guidance and support. The last report noted that service users’ plans would benefit from rationalising so that they contain only information that is accessible, clear and easy to understand, relevant and up to date. In particular, plans needed to be person centred making sure the person they are about is at their heart. This has received some attention but still largely remains to be done. At present it is therefore difficult for service users to be confident staff have the information they need to make sure each person has the personal support that best suits them, and receives timely, appropriate attention from health services to maintain optimum health. Staff said service users are supported to be independent in managing their personal care. However their records are not designed to help staff do this. For example, a service user assessed by the occupational therapist as needing adaptations and aids to daily living following an illness some months ago, also has a care review noting altered awareness of road safety. The occupational therapist assessment requiring adaptations is noted in the communication book, but is not evident in personal care records, while none of this is reflected in a revised risk assessment and service user’s plan. This means the service user cannot be sure of the right staff support to help safely manage the new risks and remain as independent as possible. The acting manager explained that the adaptations have not all been put in place as the service user had made good progress and no longer needed them. There is no record of this decision, so this needs to be clarified with the occupational therapist. The service user needs to be sure the occupational therapist’s advice is properly recorded in the service user plan, so that staff are all giving the right support. Risk assessments are out of date and do not reflect current needs. Staff spoken to were unsure of the risk assessment process. This could mean either that service users may be exposed unnecessarily to risk of harm, or find staff are extra cautious thus restricting their independence and choice. Some work has been done to assess service users communication needs and to train staff in communication skills, but a number of service users here have little or no verbal communication so this process must be ongoing. There is very little evidence of improved communication practice which would support Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 18 service users to gain more control over their life, for example easy read or symbolised information about aspects of daily life such as staff on duty, meals and activities. Most service users have lived at Brook House and 58 Ash Grove for some time. Changes in needs and living arrangements mean that community care assessments carried out before moving in are out of date so do not show the support the service user now needs or is given. After discussion during the inspection the acting manager recognised the need for community care assessment reviews and updating, and has begun discussing this with one social worker. Health records are limited, and health action plans were not available on the day of inspection. It was therefore difficult to track service users’ contact with health care agencies, and the outcomes. It is not clear how staff make sure they follow service users’ health progress, or make sense of the details, as information is being recorded in different places. Staff explained all service users have a Health Action plan but that these had recently been taken away to make improvements. As staff are rightly concerned about keeping health records in the meantime they have started recording health care activity separately to ensure important information is not lost. This suggests some confusion about Health Action plans (which belong to service users as their own record and communication tool when attending health care appointments) and health records, which should be part of the service user’s plan. A full health record is essential, bringing together in a planned way all the information about the service user’s well being and progress. This is very important to make sure service users have the right help from staff to look after their health properly, and access the right health services in a timely way when needed. Service users need staff to change the way they think and work, so that they make sure what they do is best from the service users’ point of view. This is called a person centred approach. Staff need more guidance on good practice. The staff communication book shows some staff still think and do things according to what they think is best, but in a way that can be undignified and disrespectful, leaving the service users own interests out of the picture. This needs to be changed. Phrases used in the communication book to alert staff to what needs doing, show staff sometimes still think of themselves first rather than how the service user might feel. They begin with such examples as ‘please make sure ’X’ does… ’ or ‘Y’ has to have…’ rather than ‘‘X’ needs you to help her…before she goes out so that she…’ or ‘‘Y’ will need your support to… so that he can make sure he has…’ Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 19 One entry in the communication book says someone’s bed had been ‘stripped and washed but left unmade to discourage (the person) from getting into it during the day’. This is not only undignified for the service user but it is also the wrong way to go about things. It is not right to ‘manage’ service users in this way through controlling what they can and can’t do. This example and observations during the inspection showed that while some staff are caring and treat service users with dignity and respect, other staff need very clear guidance about attitudes and behaviour that is not acceptable. For example, service users who are anxious or distressed need staff to be patient, reassuring and to pay attention to their feelings or perhaps need to be offered a distraction, but one service user who was upset was told not to make a fuss, while another, already restless, was kept waiting some time for a promised activity. Service users need to be confident they will always be treated well and supported sensitively, so they also need to know that poor practice will not be tolerated. Staff need to have confidence in management systems for monitoring the quality of their work and supervising their development, and to know that managers will identify and respond robustly to poor practice. A complaint previously made to the Commission had raised concerns that another service user was being prevented from going back to bed during the daytime. Evidence from care records show sleep apnoea has recently been diagnosed, a condition that can cause frequent night waking and lead to extreme daytime tiredness. The service user needs to be sure staff have up to date information about this in the service user plan, showing them how to help him get enough rest so as to get the best out of life. Some older people use this service. Staff still need training to understand what extra help people need as they get older, including special conditions such as diabetes, stroke and dementia. The communication book mentions skin problems and an ulcer, indicating training in skin care and tissue viability is needed to help service users make sure their skin is protected. Staff spoken to were also unaware of the right to assessment procedures to detect the possible early onset of dementia, for people with Down’s syndrome, although this is relevant to this service. No training has been provided in understanding and caring for someone with dementia, although prior training can give staff the skills to respond well if early signs of dementia are showing. If any service user were to develop this condition, having well-trained staff able to offer early support would offer considerable comfort from the outset for what can be a very frightening time. Service users need to be sure staff know and understand their medication needs and that their medication is stored and handled appropriately for their safety. A preliminary inspection showed some aspects were being managed in Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 20 accordance with Royal Pharmaceutical Society guidance but that some practice in relation to handling of medication needed attention. The following matters were noted on the day of inspection, and the pharmacy inspector has therefore been asked to carry out a full inspection of the medication systems at this service: Service user’s medication profiles did not include their photograph. The medication cabinet for Brook House is inappropriately located in a (currently unused) service user’s bedroom. The controlled drugs cabinet is now in use as the medication cabinet for 56 Ash Grove. This means there are no suitable storage arrangements for controlled drugs should this be needed, although none are prescribed at present. There is no evidence to show medication is checked in and signed for on arrival from the pharmacy. The communication book contains a reference to staff concerns about a medication error on 22/3/07 but this has not been notified to the Commission as regulations require, and there is no evidence action has been taken in response although a form and procedure exist for this purpose. No service user currently takes responsibility for their own medication. One service user’s file contains a consent to treatment form, but this is unsigned and undated. Service users’ ability to take responsibility for their own medication, and if not, to give informed consent for staff to administer their medication, needs to be assessed and recorded. Their signed consent needs to be obtained and retained on their personal record, or, where this is deemed inappropriate written evidence obtained to this effect. Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 21 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The provider has procedures available that explain how to make a complaint and support service users to do so, but it is not clear if service users here are aware of this procedure or would be able to use it to raise concerns they might have. Staff have had training in safeguarding people but those spoken to were unaware of adult protection procedures or how to respond to behaviour that challenges the service. More training and support is needed. Changes of manager, and staffing instability, has left some staff confused about good practice standards. EVIDENCE: The providers have introduced complaints procedures for service users and their supporters, including in formats service users can readily understand and use. However it is not clear if all service users here are familiar with these, nor how service users with significant communication problems are supported to understand and use them should they wish to make a complaint. Service users need staff who support them to understand about making and responding to complaints, recognise when a service user has concerns about the service they are receiving and can support them to voice any concerns. The complaint record showed one service user had been supported by the Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 22 manager to make a complaint when he was unable to go to church. This was resolved satisfactorily for him, although the acting manager has been reminded that details of response time and outcome needed to be included in the record. However, staff spoken to had not understood why it was important the service user had been supported to voice this complaint. It is evident from observation and discussion during the inspection that other service users may be dissatisfied with the service, but there is no evidence they know how to express their concerns as a complaint or that these concerns are being effectively recognised, understood and responded to. For example one service user who previously enjoyed a quiet life was not consulted about a change of companion and has made it clear he finds the extrovert behaviour of the person who has moved in intimidating. The service user has not been supported to make a formal complaint, so that this can be properly investigated and action taken that is acceptable to him. Instead the service has responded by supporting the service user’s choice of retreat elsewhere in the property where he elects to spend most of his time, although this choice lacks proper facilities such as heating. The acting manager was advised to seek a review of this sharing arrangement with the placing authority, to assess the needs of both service users and respond accordingly. This was requested promptly before the inspection concluded. Another service user was kept waiting half an hour to go for a walk and became anxious and agitated while waiting. This service user has limited communication skills. In such circumstances, staff need to be alert to the possibility that a service user may wish to make a complaint, and ensure they have the support they need, such as an advocate, so that they can do so. This example illustrates clearly why it is important service users have the support they need to raise concerns about the quality of service they receive. With an existing complaint on record that a service user was not supported to go to church, this would not be the only service user with concerns about being kept waiting or unable to do what they wanted, and a complaints analysis might show staffing deployment needs investigation. A complaint about the service had previously been made to the Commission and the providers were asked to investigate. This was responded to in a timely way. The providers have overseen this process, followed up and reported to the Commission on the outcome of the first investigation, with an improvement plan to address identified shortcomings in the service. A second complaint concerning a number of practice and service management issues was made to the Commission, and is currently being investigated by the service (see below). This included that the concerns had been raised with the Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 23 acting manager but that a satisfactory response had not been received from the service. This had not been recorded in the home as a complaint. The providers have been asked to investigate the second complaint and a report on this investigation is awaited. The first improvement plan has been considered in the course of this inspection, to assess the effectiveness of action taken to improve the service. Evidence in this report shows that significant concerns remain, so further action is needed to address underlying issues. The providers will therefore be invited to respond to all concerns and to the findings of this report with detailed proposals for improvement, and the Commission will be closely monitoring the outcome. The providers have in place safeguarding policies and procedures, and the acting manager is familiar with local procedures for responding to suspicion of abuse. She confirmed that all staff have had training on safeguarding people, and information about local procedures was displayed on the office notice board. However the effectiveness of this training must be questioned, as staff spoken to were still unclear about what constitutes abuse and the procedures to follow in the event of any concerns being raised. Staff spoken to had not been receiving regular formal supervision to monitor and support them in their work. Some had only one supervision in 8 months. The acting manager explained that as she had been working shifts to avoid the need to use agency staff, she had been working alongside staff so was able to monitor practice and provide guidance. However this does not substitute for the benefits of protected time for regular supervision. An uncoordinated record system compounds the lack of consistency in information about service users needs and how to meet them. This is leading to variation in the way staff respond to service users as they rely on what they think is best. Staff are aware that without sound guidance they could expose service users to unacceptable risk from practice which may constitute abuse. They have expressed concern about this possibility when spoken to in the course of inspection, having received warnings about abusive behaviour but seem confused about what this is. The factors underpinning variable practice need to be addressed and attended to robustly. Staff need clear guidance on what is expected of them, what is unacceptable, and how good outcomes for service users are to be achieved. Sound systems of training and supervision are essential to enable them to achieve this confidently. Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 24 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 29and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The two houses are suited to their purpose, well located for access to community facilities, clean and fresh and maintained in good order. Communal areas are simply decorated in a pleasing modern style. Service users bedrooms have been personalised, although two long landings at Brook House have an institutional air. The empty bedroom at Brook House is undersized and this must be made clear should the room be offered to prospective service users. Some upgrading work has been done and more is due to be carried out in the near future. EVIDENCE: Both houses are suited to their purpose, located on a residential estate with buses, shops and leisure facilities nearby and in the local town centre. 58 Ash Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 25 Grove is a small house for two people, it is cosy and welcoming throughout while Brook House (no. 56) provides large spacious accommodation for 8 people. Ground floor accommodation in both houses is homely, clean and comfortable with service users having a spacious kitchen, washing and communal areas with good facilities and well tended shared gardens. Each service user at Brook House and 58 Ash Grove has a single bedroom which they have personalised. At Brook House these are located on two long plainly decorated landings giving an institutional air, but individual rooms are welcoming. Communal facilities consist of one large lounge diner in each house with the addition of a conservatory at Brook House. The latter also has a large kitchen with table, where people can sit to do activities or to socialise thus providing some additional communal space. In view of the number of people living here it may be good practice to consider whether the one large room at Brook House could be converted to provide a more versatile arrangement. Eight of the single bedrooms at Brook House are of an adequate size but the ninth is small and the tenth is undersized. The providers are aware of this room’s limitations but currently propose to continue offering it to prospective service users, They need to be mindful of good practice in deciding on the use of this room, paying careful attention to space needed, so as not to disadvantage any occupant. A prospective service user and representative(s) need clear information about the room size and facilities offered, and assessment of personal space and equipment requirements, so that they can take this into account early on and reach a realistic decision about the suitability of the service offered. There are sufficient bathrooms for the number of service users in each house but those in Brook House would benefit from some refurbishment to give them a more homely feel. For staff use there is an office in Brook House and a sleeping-in room in each house. Furniture and furnishings are generally appropriate to service users needs. There is a single very big dining table in Brook House, which enables all service users, staff and visitors to eat together if they so wish. However this is quite formal for everyday, and could be intimidating for some service users. At one observed mealtime service users sat spaced well apart and the atmosphere was subdued, rather than being used as a chance for friendly conversation about the day’s events and forward plans. A previous recommendation was for consideration to be given to dining furniture that can provide more versatile and companionable arrangements and allow flexible use of the room. It is understood this is being considered but the acting manager said no decision had yet been finalised. Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 26 Two service users have previously been referred for an occupational therapist’s assessment, with recommendations made for equipment and adaptations in the home to aid independence. Some but not all the recommendations have been implemented, and an up to date review needs to be sought to determine current needs. The home is clean and fresh. Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 27 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,33,34, 35 and 36 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. There has been a significant change in the staff group since the previous inspection. A third (acting) manager is in post within a year. An untrained staff team is feeling confused and unsupported regarding what is expected of them. The team is not yet complete and staff feel overstretched to meet service users’ needs, but recruitment remains problematic. The manager covers shifts herself to avoid using agency staff but at the expense of staff support and development, further contributing to low staff morale. It is essential to establish a strong staff team with enough staff to effectively addresses the specific needs of this service. . EVIDENCE: Service users cannot be confident the present staffing arrangements are sufficient to provide them with the support they need, to enable them to follow a lifestyle of their own choosing. Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 28 The staff group has continued to change over the past year so has not yet developed as a team. Some staff report that they still do not have clear contracts or job descriptions. There is a staff group of 9 care workers to support the service users in both houses, comprising a mix of full and part-time posts to a total of 243 hours, plus the acting manager. One care staff explained she has a dual role, combining caring with cleaning although her hours of deployment in each role remain undefined, which she finds confusing. These staffing hours are unduly low for the size and nature of the service, which comprises two households and people with substantial support needs. The acting manager explained that there is a continuing programme of recruitment to fill remaining vacancies, although she is concerned that the service still carries a poor reputation discouraging applications from prospective care staff. However as current staff are already working extra hours to cover the shortfall, recruitment to existing vacancies will not improve matters. Staffing levels need to improve. Rotas seen show a minimum number of core staff are on duty throughout the daytime and evening, with one staff at 56 Ash Grove and two at Brook House, and a member of staff sleeping in at night at each house. There is usually only one extra staff on duty through the day at weekends. This allow little scope for each service user to follow an individual lifestyle or have one to one time with staff. Current staffing arrangements are thus effectively perpetuating previous institutional practice as they. Service users have a right to expect a more enlightened approach from the present providers, and need to know this will improve. Person centred planning seeks to encourage and support service users to develop a more personal lifestyle. To promote this effectively, staffing levels need to be increased accordingly and service planning needs to take this into account. Service users need information about staff deployment (rotas) to be presented clearly, so that they know there are sound arrangements made for their support. It would be good practice for this information to be made available in a format they can understand and use. Rotas need to list all staff including relief, show times of day accurately and state who is the shift senior. The senior or designated senior responsible for taking decisions needs to be identified on every shift. This is a management responsibility and it is not good practice to leave this to shift staff to sort out. Sufficient time needs to be made available for the senior to provide a verbal hand over at change of shift. This is not happening at present and needs to be built in to the rota. Service users need to know that the staff coming on duty have the information they need to provide continuity of care, so staff must have sufficient time allowed for key information to be shared and discussed. Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 29 Current reliance on the staff communication book and handover sheets focusing on administrative tasks is a poor substitute for good practice. Pending full staffing levels being achieved, the acting manager is keen to avoid the use of agency staff so works shifts herself. While the aim is commendable this has not been good use of management time. It detracts from the time and attention available for staff support and development, administration and service development, all aspects highlighted in this report as in need of focused attention. A more creative approach to staff recruitment and deployment may be appropriate, for example by using ancillary staff. Consideration needs to be given to the benefits of dedicated administrative and domestic staff This service would benefit from the appointment of a well-trained and very experienced deputy able to share management responsibility, for example for staff support and development. There are currently no male staff although there are four male service users, meaning service users have no opportunity for gender choice for support should they prefer this. This needs to be taken into account in all future staff recruitment. Service users need to know they are supported by competent and qualified staff who are appropriately trained, so that they have the knowledge and skills to meet their needs effectively. This is being addressed at present. The acting manager has a relevant registered manager qualification. Many of the staff group have relevant care experience, and some have appropriate training from previous employment. The most recent staff have completed induction training to Learning Disability Award Framework standards. Staff are being encouraged to follow National Vocational Qualification programmes and the target of 50 staff trained to National Vocational Qualification level 2 in Care has now been met. A programme of ongoing training has been delivered to this staff group over recent months relevant to this service user group, including communication skills, person centred planning, safeguarding adults and medication. More specialist training needs to be provided for all staff. Some but not all staff have up to date safe working practice training and this needs to be completed as soon as possible for all staff. The providers have a corporate induction and effective e-learning training programme. Combined with National Vocational Qualification (NVQ) programmes and access to specialist training, this should ensure staff receive the training necessary to provide them with appropriate knowledge and skills to care for people with learning disabilities. To support this and also enable Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 30 the acting manager to access online support and guidance, in addition to assisting with administrative tasks, the home needs to have up to date computer and office equipment. Staff show commitment to the care and support of service users at this home, but changes of manager and different approaches have left them confused about what is expected of them, and feeling unsupported. Staff have not been receiving regular formal supervision to monitor practice and support them in their work. The acting manager explained that as she had been working shifts to avoid the need to use agency staff, she had been working alongside staff so felt she was able to monitor practice and provide guidance in this way. However some staff spoken to had only had one formal supervision since the acting manager’s appointment in October 2006. This means they lack the opportunity to explore any work-based concerns in confidence. The manager has had no protected time with each staff member to get to know them, provide guidance and support, understand how they approach their work and any difficulties they are having and address individual practice, training and development issues. Staff meetings provide another important opportunity for communication and training, and also need to take place regularly. An acting manager was appointed following the resignation of the previous manager 8 months ago, who receives extra supervision and support from an acting area manager. However, no application for registration has yet been made. This means there is currently no formal on-site accountability for the quality of service, which therefore rests with the Responsible Individual. Service users need to be assured staff who support them can be trusted to follow sound practice and know how to safeguard their well-being. For this to happen robust recruitment procedures must always be followed to check there is no evidence of poor practice, and staff must have up to date training in safeguarding people. The acting manager’s recruitment details were checked as she had been appointed since the last inspection. The record seen confirms the required checks have been carried out. Records were not available for the two other staff appointed in the last year, so these will need to be checked at the next inspection.. Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 31 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. An experienced acting manager was appointed when the registered manager left nine months ago, who has worked on addressing the requirements still outstanding from the previous inspection. While some progress has been achieved notably in introducing a staff training programme and an improved system for managing health and safety, other matters still need attention. The acting manager has asked for more staff to help her improve the service but staffing levels are still unchanged. This stretches her time too thinly and she has been unable to do everything needed. An application for registration of a manager needs to be submitted as soon as possible. EVIDENCE: Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 32 The acting manager is qualified and experienced in this role but feels herself challenged and with limited resources, to turn around a service with poor administrative systems and complex staffing and practice issues which a series of management changes had compounded rather than addressed. She feels the providers have underestimated the task and has raised this with her line manager but her request for more staff has not so far been agreed. Pressure on her time has been compounded by staff recruitment problems. She works some shifts herself but now concedes that this decision has only added to the difficulties by reducing the time she has available for management tasks. Although progress was being made towards achieving a more person centred service a year ago this has not been sustained, complaints have been received about the service and staff morale is low. Staff have had some training in safe working practices. This needs to be brought fully up to date and all gaps filled. Management colleagues from other services in the group have loaned staff for specific tasks such as setting up sound health and safety systems and procedures. A member of Brook House staff now has responsibility for this aspect of the service. It is illustrative of the problems faced, that training in safe working practices is not yet up to date for all staff, and this staff member still awaits her own health and safety training. The office computer system needs replacing. The lack of a computer is further hampering progress as the manager is unable to access administrative systems and sources of guidance, support and in-house staff training materials. The process of restoring this service requires skilled management but this needs to be backed by organisational commitment to improved resources, so that management time and skills can be directed to where they are most needed. Attention must be focused on the issues raised in this report, and the clear indication of the need to review the staffing complement. The primary aim must be to improve direct support for service users, but consideration also needs to be given to allowing for more delegation of administrative tasks and freeing more management time to attend to matters of staff development. Staffing resources at all levels need to improve if the necessary progress is to be achieved. In particular it would be good practice to consider the appointment of a skilled and experienced deputy manager able to bring complementary skills to the task of staff support and development. Sound staff management, communication and support procedures are essential for restoring staff confidence and morale. A strong well-supported staff team is Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 33 key to developing a service that is open, accountable and a pleasure to live and work in. Service users and staff need clear effective and trusted ways of communicating and must be confident their views and concerns are listened to and taken into account in service development. A full quality assurance system needs to be implemented and the views of service users and other stakeholders obtained on service quality. These responses need to form the basis of an annual report and development plan for the service, to be provided to service users and the Commission. The home has not had a registered manager in post since September 2006, so a decision must be reached on this and an application for registration must be made. An acting manager was appointed following the resignation of the previous manager 8 months ago, who receives extra supervision and support from an acting area manager. However, no application for registration has yet been made. This means there is currently no formal on-site accountability for the quality of service, which therefore rests with the Responsible Individual. Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 34 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 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 1 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 2 33 1 34 2 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 2 1 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 1 2 X 2 X 1 X X 2 X Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 35 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 12, 15 Requirement The service user plans must be completed with the service users, cover all aspects outlined in NMS 2.3, 6-21 and be structured in a person centred way which is clear and easy to use.(timescale of 30/06/05 , 28/02/06 and 08/09/06 still to be met) Suitable arrangements must be made to ensure the home is conducted in a manner which respects the privacy and dignity of service users Individual risk assessments must be fully completed and underpin action plans for service users personal skills development A record of food provided for the service users should be kept, with sufficient detail to show individual choice and any special diet. This is an ongoing requirement Records must be kept of the details of any specialist health care plan and nursing care for each service user. There must be a complaints DS0000065900.V339081.R01.S.doc Timescale for action 01/09/07 2. YA18 12(4) 01/09/07 3. YA9 13 01/07/07 4. YA17 Sch 4(13) 07/06/07 5. YA19 Sch 3 07/06/07 6. YA22 22 07/06/07 Page 36 Brook House and 58 Ash Grove Version 5.2 7. YA23 13(6) 8. YA29 23(n) 9. YA33 18(a) 10. YA34 19 procedure appropriate to the needs of the service users, and a system for considering complaints made by service users or their representatives Arrangements including staff training must be made to prevent service users being harmed or suffering abuse, or placed at risk of this Suitable adaptations must be made and equipment supplied for service users who need these. There must at all times be suitably qualified competent and experienced staff at the home, in sufficient numbers for the health and welfare of service users. Staff records must be available to show robust recruitment procedures have been followed, with 2 references and CRB and POVA checks made, prior to commencing work in the home. All staff working at the home must be appropriately supervised by suitably trained staff, including access to specialist supervision where appropriate A system must be introduced for consulting service users and their representatives, reviewing and improving the quality of care provided by the service. A report on the outcome must be provided to service users and to the Commission 07/07/07 07/07/07 07/06/07 07/09/07 11. YA36 18(2) 07/07/07 12. YA39 24 07/07/07 Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 37 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 YA2 Good Practice Recommendations Details of room size and facilities should be made clear to any prospective service users who may be offered the smallest bedroom Communication needs assessments should be recorded for each service user with specialist communication needs, and used as the basis for establishing a communications strategy for the service Consideration should be given to the layout and flexible use of communal rooms Two signatures should be obtained for all financial transactions of service users money. service users should be supported to look after their own monies Adequate time should be provided at shift change, to verbally hand over information about service users and the service to the next senior on duty Macintyre policies and procedures should be introduced to the staff with staff signing and dating that they have read and understood them. 2. YA6 3. 4. 5. 6. 7. YA24 YA23 YA23 YA33 YA40 Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Worcester Local Office The Coach House John Comyn Drive Perdiswell Park Droitwich Road Worcester WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Brook House and 58 Ash Grove DS0000065900.V339081.R01.S.doc Version 5.2 Page 39 - 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. 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