Inspection on 23/01/09 for Bullpond Lane

This inspection was carried out on 23rd January 2009.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bullpond Lane 12/10/07

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

Extracts from inspection reports are licensed from CQC, this page was updated on 20/03/2009.

CARE HOME ADULTS 18-65 Bullpond Lane 60, Bullpond Lane Dunstable Luton Beds LU6 3BJ Lead Inspector Angela Dalton Key Unannounced Inspection 23rd January 2009 10:30 Bullpond Lane DS0000070212.V373910.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 Bullpond Lane DS0000070212.V373910.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. Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bullpond Lane Address 60, Bullpond Lane Dunstable Luton Beds LU6 3BJ 01582 472580 01582 478875 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) londonroad@tiscali.co.uk Milbury Care Services Ltd Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender Either Whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD The maximum number of service users who can be accommodated is 6. 2. Date of last inspection 12th October 2007 Brief Description of the Service: Bullpond Lane home is owned by Voyage (formerly Millbury Care Services) a subsidiary of the Paragon Healthcare Group. The company has been established for 18 years to provide residential care to people with challenging behaviours due to their complex needs. The home had been developed from a private property located in a residential part of Dunstable in Bedfordshire, in close proximity to local facilities (Dunstable town centre) and transport links. Bullpond Lane has six en-suite bedrooms - two of these were on the ground floor. Each was fitted with a toilet, hand basin, bath, and overhead shower. The smallest bedroom, according to the home’s Statement of Purpose was 12.4 sq m excluding the en-suite and the largest 24.05 sq m. All of the bedrooms have been individually decorated and included a bed, a chair a table, a touch operated lamp and matching curtains and bed linen. Service users can individualise their bedrooms with pictures and small items of furniture from home if they wished. In addition to the bedrooms the premises included a lounge, quiet room, conservatory, dining room, kitchen, laundry, office, a number of store cupboards, a downstairs toilet, a fully enclosed garden and parking for several cars to the front and side of the property. The home had been decorated and furnished to a high standard. A TV and 2 music systems were available for service users within the communal areas. Weekly fees range from £1450 to £1500. Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. One inspector conducted this unannounced site visit 23rd January 2009 between 10.30am and 6.25pm. The manager was present for the latter half of the inspection. Two people were case tracked: The inspector followed the care of people who use the service to ensure the care they receive is reflected in the care plan and meets their individual requirements. The case tracking process cross-references all the information gathered to confirm that what Inspectors are being told is actually happening and reflects the Statement of Purpose, which contains the aims and objectives for the service. It included discussion with service users, staff and the manager. We looked at a variety of documentation which illustrated how the needs of people who use the service are met. The service completed an Annual Quality Assurance Assessment (AQAA) report and we received surveys completed by people who use the service and staff which provided us with additional information. People who use the service are well cared for and staff focus upon individual needs and ensure that people develop their skills and independence. What the service does well: Staff told us what the service did well in the surveys they returned to us ‘Help the service users live as independently as they can.’ ‘The service meets the needs of staff and service users very well. They take full interest in how everyone is and if there are any issues. I am happy to be a part of this company and am pleased with the cooperation from others.’ Staff ensure that they are equipped to meet people who use the service’s needs by ensuring that staff are available at peak times. Despite some of the staff being new to the service thy have made efforts to get to know individuals and this was observed during our visit. Despite the recent challenges of staff and management changes people who use the service have remained the focus of the staff. Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The manager must register with the Commission for Social Care Inspection to ensure accountability for the running of the service. Care plans require more expansion to assist staff in fully meeting the needs of people who use the serviced. This is necessary to meet the identified health needs which have been assessed and also in the accompany risk assessments which do not provide staff with details on monitoring, managing or meeting an identified risk. Care plans have identified various health needs such as autism, thyroid problems, psoriasis, diet management and healthy eating and risk of choking and moving and handling. Additional information is required to support care plans such as weight records and skincare records. People who use the service could benefit from a more user friendly menu and inclusion about meal options as both a cooked lunch and dinner were served on the day of inspection. The medication system does not assure the safety of people who use the service and some improvements are required to recoding and administration practices. Some maintenance issues need attention and a ‘snagging’ review would determine what work is needed as we identified some missing fixtures and fittings during our visit. The dishwasher requires replacing as it is broken and the television picture was distorted. The manager plans to address all these issues. The recruitment practices must be reviewed to ensure that recruitment checks are satisfactory and that people who use the service are well protected. There are currently some oversights. Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 7 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. Bullpond Lane DS0000070212.V373910.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 Bullpond Lane DS0000070212.V373910.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information needed to help them make an informed choice about moving into the home and individual needs are assessed to ensure that they can be met. EVIDENCE: The service users’ guide is in a pictorial format and contains photographs of each person who uses the service’s bedroom. This is kept by each individual and is personalised so that it relates to their home. It contains sufficient information for people who use the service to make an informed choice about where to live. It includes the skills and experience that members of the staff team have and also those of the senior management team. The new manager is exploring ways to make it more user friendly to those who may not be able to read and are more familiar with Makaton and other ways of communicating. The service has not had any new admissions since the previous inspection in October 2007. There was evidence that the needs of people who use the service had been assessed and documentation was able to demonstrate that the service could meet the identified needs. There is currently one vacancy and the manager is aware of the admissions process and the assessment paperwork. The needs of existing people who use the service will be a major consideration to ensure that everyone is happy with the potential changes that may occur when a new person moves in. The moving in process would occur Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 10 over a period of time building up from tea visits to overnight stays. This would ensure everyone was familiar with the process to minimise disruption. Each person who uses the service has a contract which details the terms and conditions of the service and the expectations that they can have of their home. Bullpond Lane DS0000070212.V373910.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are the focus of the service but care plans must be expanded to illustrate how the needs of people who use the service are monitored, managed and met. EVIDENCE: Care plans have been reviewed since the previous inspection and the format has been developed. The manager is exploring how the layout can be more user friendly but some sections are in a pictorial format. We looked at two care plans were personalised and focused upon how individual needs are met but more information is required. In one care plan it stated that food was to be cut up in small pieces but with no information about what size. Records do not reflect if there are difficulties with swallowing or reflect that there may be issues with large amounts of food or risk of choking. No specific information was provided for identified health needs. A record reflected that specific needs such as autism, psoriasis and under active thyroid had been identified but there were no corresponding guidelines for staff to follow under those headings. One person who uses the service is trying to lose weight but there Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 12 were no weight records in place and guidance from the dietician had been filed with no accompanying care plan to advise staff on their weight loss or healthy eating goals. However, general information was recorded to reflect the individual’s wishes to lose weight and how they aimed to achieve this. Skin conditions were being managed as there were records of cream being applied for psoriasis but staff were unable to monitor whether the condition had improved or worsened or was responding to treatment. Behavioural guidelines were in place but did no directly relate to the diagnosis of autism on the health needs sheet. Staff were unaware of how they could identify if a thyroid condition was being managed but records reflected that it was being monitored by the GP and regular blood tests. A communication plan stated ‘uses Makaton and signs a little’ but did not specify what signs were used. Some confusing statements were recorded ‘ needs wheelchair but is happy to walk.’ It is important that clear guidance is in place to ensure that staff can monitor and manage people who use the service’s needs. The same is true of risk assessments that were not specific. We looked at moving and handling guidelines that stated ‘ support from staff needed’ but did not specify what type of support was required and by how many staff. Important information such as family birthdays and contact was included and this is often overlooked. People who use the service had signed their care plan where possible and end of life wishes were recorded. A chores list has been devised with the people who use the service and they ensure that everyone takes responsibility for tasks within their home. Each person has a set day to complete their laundry and receives one to one support from staff. A menu is also devised with their participation. Regular house meetings occur and minutes are recorded. An advocacy group is available if people who use the service wish to access it but all currently receive support from their families. People who use the service stated that they met with friends and family and that staff observed their choices. We saw this in action when individuals were asked what they wanted to do on their return from day care. Work has not yet commenced on introducing person centred planning but staff have dates to attend some drop in workshops run by social services that they plan to attend. This will enable information to be available about individual wishes and aspirations. The manager plans to ensure that the care plans are regularly reviewed to ensure there is up to date guidance for staff to follow. This is essential as there have been several changes within the staff team recently. Bullpond Lane DS0000070212.V373910.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): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The leisure and employment needs of the people who use the service are met in a flexible way. EVIDENCE: The people who use the service attend a variety of day care services, such as college and day centres. They also attend clubs and go out to the local pub, cinema and shops. There was a trip out bowling on the afternoon of the inspection. The service has a seven seater car to ensure people who use the service can go out to activities or visit family and friends. One person who uses the service told us that they enjoyed living in their home and staff helped them to do things they liked. They were preparing to go swimming and explained that they had decided to do this to lose weight, as this was an activity that they enjoyed. They said that they had two homes – the one that their family lived in and they visited fortnightly and the one they lived in on their own. Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 14 We observed people who use the service and staff assisted them to do activities that they enjoyed. The rota is arranged so that people who use the service can attend college and daycare and the manager ensures that this occurs by ensuring necessary staff are available at ‘peak times’. The rota reflected this. There is an activity folder to reflect which activities people who use the service enjoy and also provides information on local leisure facilities. People who use the service go on holiday with their families and the service does not currently provide this. The manager stated that this situation would be reviewed, as some parents would become less able in future to provide holidays. The service works closely with families. Most people who use the service return home on a regular basis, particularly over weekends and public holidays. One person who uses the service frequently returns home to his family as they live locally. This is not always planned and they are not always appropriately dressed. This occurred during the inspection – the person who uses the service left to visit their parents. The manager and family discussed the situation and the person who uses the service will return after the weekend. This happens on a regular basis and staff have a god relationship with families. Menus are discussed with the people who use the service but they are not in a user friendly format. The lunch menu stated ‘hot dogs’ were going to be served. Staff prepared sausage, chips and vegetables. The menu for dinner was fish, potatoes and vegetables. People who use the service were served two hot meals – one person who uses the service chose to make a sandwich for lunch but others were not offered a choice. One of the people who use the service confirms that they regularly go food shopping twice a week with staff. Bullpond Lane DS0000070212.V373910.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health needs of people who use the service could be better recorded and the medication system does not ensure the welfare of people who use the service. EVIDENCE: As discussed under the earlier heading of ‘Individual Needs and Choices’ further information is required to inform staff how to better meet the needs of people who use the service. Staff plan to attend workshops on devising Health Action Plans which will provide a consistent format for all people who use the service. There was evidence that people who use the service receive the necessary support form health and social care professionals. Staff confirmed they felt they had accessible support to ensure that they could meet changing needs. We inspected medication records of two people who use the service. A record of medication storage temperatures was kept to reflect that medication was safely stored. Copies of prescriptions are kept to reflect that the correct medication is received into the service. The Medication Administration Record Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 16 sheets (MAR) were inspected and the code to reflect that ‘Social Leave’ had been taken was used. There was no record of the amounts of medication being checked in or out of the service. It was not possible to see if medication amounts were correct because no record had been recorded whilst medication was away from the service. The reverse of the MAR sheet had not been used to reflect ’Social Leave’ had been taken and which staff had been responsible for checking out medication. One medication still featured on the MAR sheet despite no longer being required. This could cause confusion and needs to be removed. Handwritten instructions were not comprehensive and did not describe the route or amount prescribed. Records were incomplete for the administration of eye and ear drops and could cause cross infection if administered to the wrong eye or ear. One person who uses the service previously self administered but staff had taken over this responsibility due to the lack of lockable space – an alternative was being purchased. Thee was no record to reflect that competency and ability to self medicate had been assessed. Staff were administering medication but leaving it to the individual to notify them when they had taken medication. MAR sheets were not specifying the exact time medication should be administered – instead stating morning. This did not ensure that medication was being given at the same time each day and may result in medication being less effective. We observed eye ointment being administered at 11.30am before the person who uses the service was going swimming forty five minutes earlier. This is less effective treatment than having the ointment administered first thing in the morning. Bullpond Lane DS0000070212.V373910.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff have an awareness of the company protocol to ensure that people who use the service are protected. EVIDENCE: There were records to reflect that details of complaints are kept and the action that is taken. The manager plans to expand the current recording system to incorporate how concerns and compliments are responded to provide a more rounded picture of the service. The revision will also enable any staff member who records a concern to record the action taken. Monthly house meeting provide people who use the service with the opportunity to share their thoughts and feelings on issues that may escalate if they did not have a forum to share their concerns. There is also a link to an advocacy group and reviews with Social Services should a person who uses the service wish to talk to someone independent of the staff team. One person who uses the service told us if they were not happy that they would talk to their keyworker and that they knew how to make a complaint. Staff have received company training to enable them to deal with aspects of abuse. We have been assured that all staff will be made aware of the local authority’s procedure. We checked two financial records for people who use the service and found them to be in good order. Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 18 Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service had a homely atmosphere and the manager is aware of how to address maintenance issues. EVIDENCE: The service is close to Dunstable town centre and within walking distance to the local pub. Helpfully there is a zebra crossing outside the house to assist people who use the service in road safety. The service is in fairly good condition but some attention will be needed to decoration in the near future as some of the walls are scuffed and discoloured. The dishwasher was out of service when we visited: maintenance records reflect that this had been reported on three occasions. Because the water is not heated above 43°C it is not sufficiently hot to wash dishes, which is why a dishwasher is required. Staff are ensuring infection control is observed in the meantime. The manager confirmed that it was on order and they were waiting or confirmation of delivery. The television in the lounge had a lilac coloured picture and was distorted, therefore making it difficult to watch. The manager Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 20 stated he would ensure that a new one was ordered. Staff confirmed that this problem had only recently occurred. The laundry was in good working order and the washing machine has a sluice facility. This ensures that soiled linen can be properly and safely washed. The service also uses alginate bags which dissolve when washed. These are for using with soiled linen and reduce the amount of handling by staff of soiled items. The manager plans to complete a ‘snagging list’ to ensure that the fittings in the service are in place as some items are missing: toilet roll and hand towel dispensers were not available in all toilets. Shower curtains or screens were not in ensuite bathrooms. One service user has a fixed shower head (others have flexible shower hoses to aid staff assisting with personal hygiene) which only works when the cold water is on full. Water is still running at pressure from the tap fitting whilst on the shower setting and the temperature only reaches 35°C. The manager will ensure that this is repaired or replaced. The house was clean and odour free when we visited. The front door has a keypad and the back gates have padlocks fitted. There is no environmental risk assessment stating why these measures are in place and the manager will rectify this. Although the front door would automatically open in the event of the fire alarm being triggered, there has been no consideration made to the padlocks stopping staff and people who use the service escaping safely in the event of a fire. Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service could improve its recruitment processes to ensure more robust staff checks are carried out and people who use the service are better protected. EVIDENCE: During the eighteen months that the service has been open it has seen several changes of staff. However, the situation appears to be settling and there are currently no staff vacancies. Staff we spoke to confirmed that they enjoyed working at the service and felt supported by the manager. This is further confirmed by staff’s survey comments earlier in the report under ‘What the service does well’ section. Records reflected that staff receive the necessary mandatory training to do their job and meet the needs of people who use the service. Staff complete some training online, known within the company as the ‘L box’ facility. This provides staff with flexibility to complete their training. The manager is aiming to enrol 2 staff on an NVQ course and one member of staff has NVQ level 2. The manager is aware of the low level of NVQ qualifications within the staff Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 22 team and plans to address this. Staff are scheduled to attend fire training and person centred planning in the coming month. There are 3 staff on both early and late shifts during the week to ensure people who use the service can attend their daycentre or college. These numbers may be reduced at the weekend but some people who use the service generally return home for the weekend. At night there is 1 waking night staff and another staff sleeping in. We inspected two staff records. Head office conduct recruitment checks and it was evident that staff had received Criminal Record Bureau checks (CRB) to identify any reason why they should not be working with vulnerable people. The references of one file had been taken up but no investigation was in place to reflect why an employee had not given heir most recent employer as a reference. They had also cited senior colleagues and not the manager of their previous workplace. There was no evidence that this had been explored. References would usually be sought from a manager if they had worked in a care setting previously. Clear photographs were not present in recruitment files which are required to ensure the identity of the employee. A gap of four years was on an application form – again there was no record of this issue being explored and why there had been a gap in employment ruling out any situation that may potentially place people who use the service at risk. The education and employment history section of the application form did not provide a comprehensive employment or education history to identify the level of care experience a member of staff had. Bullpond Lane DS0000070212.V373910.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has not yet demonstrated their competence in managing the service. Health and safety could be better observed. EVIDENCE: The manager has been in post three months and has not yet registered with the Commission for Social Care Inspection. Following their induction they pan to complete a management qualification. There was little evidence of their presence in the service: all the paperwork on display in the office was devised and signed by the previous manager. Their photograph was not with the rest of the staff team’s displayed in the hall. There was no evidence to reflect that any staff of people who use the service’s documentation had been reviewed or updated. The manager stated they had been involved in resolving some staff issues that would enable the service to move forward and that they were Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 24 almost resolved. They also stated that they were waiting to become registered before making major changes. The manager has worked for the company for 6 years and was previously a deputy manager in another area so if familiar with the expectations of the company. When asked during the inspection to present the service’s copy of the Care Home Regulations and National Minimum Standards we were informed that there wasn’t a copy available. The manager will find the registration process challenging without knowledge of the guidance and regulations. The deputy manager was promoted to the post from senior support worker in September 2008. Therefore, the management team is fairly new. As the service is now fully staffed and it has a management team it stands a chance of developing and moving forward. It has had 3 managers in 18 months. One relative commented that for a new service it had experienced its problems but did not elaborate. People who use the service are asked their views during reviews and house meetings. Monthly reports are completed by a member of the company’s senior management team to assess the quality of the care being delivered, the environment and the conduct of staff. The company also issues quality assurance questionnaires on an annual basis to people who use the service, their relatives and professionals involved in their care. Staff are also asked to take part. Once feedback is received it is published in a report and made available to those ho completed the questionnaires. Health and safety records reflected that the necessary checks to ensure the safety of people who use the service and staff are carried out. Fire drills are conducted and take place at various times to include the night staff; emergency lighting checks take place monthly and hot water temperature checks are recorded. As discussed earlier the padlocked back gates are not incorporated into the fire plan and this issue must be addressed to ensure that people who use the service and staff can evacuate the garden safely in the event of a fire. The front door has a keypad and the back gates have padlocks fitted. There is no environmental risk assessment stating why these measures are in place and the manager will rectify this. Although the front door would automatically open in the event of the fire alarm being triggered, there has been no consideration made to the padlocks stopping staff and people who use the service escaping safely in the event of a fire. The dishwasher must be replaced swiftly to ensure that `good food hygiene practices are observed. Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 X 36 3 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 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 3 2 X 3 X X 2 X Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 26 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 YA19 Regulation 15 (1)(2) 12(1)(a) Requirement Identified needs must have a comprehensive care plan to enable staff to meet the needs of the people who use the service. This relates to weight management, autism, communication, management of health needs (e.g. weight records, thyroid and psoriasis) Identified risks must have a risk assessment in place to demonstrate how the risk is monitored, managed and met e.g.’ any risk of choking and moving and handling. Timescale for action 31/03/09 2. YA9 15(2) 31/03/09 4. YA20 13 (2) The medication system must 31/03/09 ensure the safety of people who use the service. Accurate records of amounts of medication must be kept to ensure amounts can be checked. If medication leaves or enters the service accurate records must be kept and the reason recorded on Medication Administration Record Sheets. Handwritten instructions must be signed and clearly reflect the DS0000070212.V373910.R01.S.doc Version 5.2 Page 27 Bullpond Lane route, dose and time medication is to be administered. A self medicating protocol must be devised to reflect how competency and ability is assessed and the safe storage and recording of medication is achieved. The time of administration must be reflected on the MAR sheet. 8. YA34 The recruitment process must 31/03/09 ensure the safety of the people who use the service. Gaps in employment must be explored and evidenced. Where a current employer or service manager is not cited as a referee this must be explored. A photograph of staff must be available as proof of identity. 8 The manager of the service 31/03/09 9 must be registered with the Commission for Social Care Inspection. They must demonstrate their competence with knowledge of the Care Homes Regulations and National Minimum Standards, which are not currently available in the service. 13 People who use the service and 31/03/09 (4)(a)(b)(c) staff must be protected from 23 (4)(c) harm. The fire plan must address the issue of the padlocked back gates. Schedule 2 9. YA37 10. YA42 Bullpond Lane DS0000070212.V373910.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. Refer to Standard Good Practice Recommendations Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Bullpond Lane DS0000070212.V373910.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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