CARE HOME ADULTS 18-65
CARE Wiltshire Furlong Close Rowde Devizes Wiltshire SN10 2TQ Lead Inspector
Roy Gregory Key Unannounced Inspection 19th March 2008 09:50 CARE Wiltshire DS0000028267.V359723.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 CARE Wiltshire DS0000028267.V359723.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. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service CARE Wiltshire Address Furlong Close Rowde Devizes Wiltshire SN10 2TQ 01380 725455 01380 729030 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.care-ltd.co.uk CARE (Cottage and Rural Enterprises Ltd) Christine Stapleton-Smith Care Home 36 Category(ies) of Learning disability (36) registration, with number of places CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The number of service users receiving residential care and accommodated in the bungalows known as Alder, Fern, Hawthorn and Myrtle must not exceed 9 in each bungalow. 14th July 2006 Date of last inspection Brief Description of the Service: The service is run by the national registered charity, Cottage and Rural Enterprises Ltd (CARE). The site is purpose-built and owned by the company. There are four bungalows, each with nine registered places. Some of the places are provided in semi-independent flats. Also on site are day facilities which provide work and skills training for people that live in the bungalows and for others who attend on a day basis. The four bungalows, known as Alder, Fern, Hawthorn and Myrtle, are run separately by house managers, each with their own staff team, but one registered manager has overall responsibility for the residential services. The facilities in each house include a lounge, a kitchen/dining room, and a utility room. Administrative support for the residential and day services is provided by staff who work in an office building. Also on site are a training facility for staff, and some staff accommodation. Fees charged for care and accommodation vary depending on each service user’s assessed needs. At the time of this inspection weekly rates varied between £625 and £770. Some service users also have additionally funded hours for one-to-one support, via their individual contracting arrangements. There is a range of information available about the service. Prospective service users have the opportunity to visit the site and tour the amenities available. CSCI inspection reports are kept in the communal areas of each bungalow. CARE Wiltshire DS0000028267.V359723.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 2 star. This means the people who use this service experience good quality outcomes.
The unannounced visit for this inspection took place between 9:50 a.m. and 6:30 p.m. on Wednesday 19th March and between 9:30 a.m. and 4:30 p.m. on Thursday 20th March 2008. The service’s regional manager, Kay Rudge, was available during the visit. Over the two days each of the residential bungalows was visited. In two of them, lunches were shared with the people who lived there, and staff who were on duty. There were other conversations with people in communal rooms and, by invitation, in private rooms. There were discussions with staff at all levels, including the training co-ordinator and job coach. The inspector looked at care plans and daily records to compare observations of care and residents’ perceptions with written records. Other records consulted included those relevant to health and safety, staff recruitment, supervision and training. All shared areas of the bungalows were visited and some bedrooms and flats were seen with the agreement of their occupants. Storage and administration records of medicines were examined. Survey forms were received from twelve of the people that live at the home; from seven relatives; and from six members of staff. The registered manager completed an “Annual Quality Assurance Assessment” for the Commission, which included statistical and developmental information about the home. What the service does well:
The survey forms received from people living at CARE, people’s relatives, and staff who work there, were almost entirely positive in the responses given. Comments from relatives included, “They have given X a happy and fulfilled life…I feel X has been lucky to have been part of such a friendly and caring community”, and “Gives our daughter excellent support and opportunities.” Another relative wrote, “We appreciate the way CARE continues to look after people as they age. CARE is working on a future development plan, which we approve and support.” Communication between staff groups, people living in the houses, and their supporters, was promoted by a number of regular meetings and also by the nature of care practices and interactions. General staff meetings, for all staff on the site, began with feedback on issues from the service user meetings, to ensure those received priority consideration. There was a quarterly forum for relatives. Minutes showed this was very much a two-way exchange of information and ideas. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 6 People living in the houses had representatives on a management committee, to ensure residents’ views were heard at the highest levels. A total communication facilitator assisted with these meetings. As a result of service user suggestion in the health and safety meeting, concerned about more traffic on the site’s roads, a zebra crossing had been installed. For each person living at CARE there was a care plan that they had signed. The plans described people’s preferences about personal care and morning and evening routines, together with detail of how the person arranged aspects of life such as laundry, cleaning, activities and interests, and what support was needed. Plans included communication guidance. In addition, people had a “person centred” plan that they kept in their own room. The aim of these plans was to support people to set goals they wished to achieve, and to put in place the things they would need to reach their goals. A record of a person’s annual review with their care manager showed a number of goals had been achieved. The care manager wrote, “X talked about the things he’d been doing since the last review with the aid of photographs. His independence and living skills continue to go from strength to strength.” The service exists to promote personal development, both in the approach to care planning and living in the houses, and by provision of a range of day activities. These include horticulture, catering and hand crafts, with basic qualifications that people can aim for. Some people are able to take advantage of the semi-independent flats in the bungalows, extending skills in managing their lives and relationships. Sometimes people are able to move on to supported living arrangements, provided elsewhere by CARE or by other providers. Many people were able to access the local community alone, for example to go shopping or attend church. All were encouraged to make use of bus passes. The development of person centred planning meant people were supported to identify activities they wanted to do. Each month they had a planning day with their key worker, and a separate “work/life balance day” especially to pursue interests and activities. There was evidence of specific support to some people in managing relationships, including access to sexual health education. A current goal someone was working on was arranging to have a friend visit for tea. People were able to keep small pets. Through house meetings, and informally over the meal tables, people agreed on division of chores in the home. Pictorial aids were put on notice boards to remind people of what was agreed. People were supported to keep their rooms and clothes clean. Each house had weekly menu planning meetings and everyone was involved at different times in helping staff with food shopping. People said they always ate well. They could choose alternatives. Those living in the flats could choose to what extent they catered for themselves. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 7 Interview records showed that people that lived in the houses were directly involved in selection of staff. The job coach had given them guidance and training on how to contribute to interviews. A staff member added to a survey form, “When interviewing for staff the service users play a major role in choosing who gets employed.” A relative added to their survey form, “There appears to be a rigorous recruiting procedure and no-one is selected just to fill a vacancy; they have to be suitable.” Newly appointed staff underwent a thorough induction with the training coordinator. In their first six months of working at CARE they completed the Learning Disability Qualification, for which the service is an accredited City & Guilds centre. All staff were required to work towards National Vocational Qualifications. There were very good arrangements for ensuring all staff received regular training. Special interest training that had been arranged included epilepsy and sexuality and relationships. Staff that were spoken with saw provision of training as a strength of the service. In a postal survey, a member of staff added, “I think training and up to date information are excellent.” Another wrote, “The service provides a great induction and training programme for staff to enable them to do their job.” There was also evidence that staff supervision was regarded as a priority monthly task. In the postal survey of people living at CARE, everyone indicated they knew who to speak to if they were not happy. One person made additional reference to the management committee. Another added; “I would tell staff if I was unhappy. I’m asked every day if I am happy.” What has improved since the last inspection?
Adding a job coach to the staff and making links with local colleges, has extended the potential for development, so people are not restricted to training and job opportunities on site. Storage of medicines in all the houses was good, as was the keeping of Medicines Administration Record charts. All handwritten additions were doublesigned, as recommended at the previous inspection. Examples were seen in care plans of guidance to individuals’ preferred ways of taking a medicine. In line with a recommendation at the previous inspection, people concerned had signed to indicate they had requested particular arrangements. Further to another previous recommendation, letters on file showed that agreement was being sought from the GP practice and the supplying pharmacy about ‘homely medicines’ that could be kept in stock, for example for relief of colds or stomach upsets. Houses had maintenance request books. These showed that any defects notified received swift attention, contrasting with the situation reported at the previous inspection.
CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 8 A number of surveys from people living at CARE, from relatives and from staff made reference to pressures on staff availability, especially at weekends. There was evidence the provider was taking measures to address this. 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. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 9 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 CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 10 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 & 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are assessed so that they are only offered a place if their needs can be met. They are given good information, and assessment stays help them decide if the home is right for them. EVIDENCE: People interested in a placement at CARE stay for a residential assessment period, during which a written assessment is compiled. If it is agreed that the person would benefit from living at CARE, and they wish to do so, they can join the waiting list. As the service offers long-term support, vacancies do not arise often. Kay Rudge said that when there is a vacancy, it is open to all on the waiting list, so the determining factor tends to be the contracting authority that can most readily arrange funding. Individual records showed that assessment information, including community care assessments, was used to agree initial care plans. The referral and admission policy had been an item for discussion at a whole staff meeting in January 2008. The service already has an accessible service user guide, but staff identified room for improvement in the literature that is made available to interested people. One improvement being considered was design of a welcome pack that would be accessed by computer. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 11 Home managers also recognised the desirability of allocating a named support worker to people staying on assessment, and improving communication generally, for example, integrating the job coach and day service staff into the assessment. Kay Rudge said there was to be a “re-branding” exercise through the company nationally, which would result in new brochures and other literature. Of the twelve responses to the postal survey for people living at CARE, all but one answered “yes” to the question, “Were you asked if you wanted to move into this home?”, one adding that they had visited beforehand. Three people did not consider they had sufficient information before moving in. There was evidence that the service recognised through care plan reviews when people were ready to move on from CARE. This might be due to development of independent living skills, or the emergence of issues requiring a different form of support. Re-assessment together with external care managers enabled people to move to more appropriate accommodation where indicated. Some people regularly stayed short periods as a respite for their usual carers. Their needs were well known, because they were all regular users of the day care services. There was a room available in one of the bungalows for people staying either for respite or assessment. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6 – 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s assessed needs are reflected in care and support plans, which are reviewed and changed as necessary, although guidance on working with behaviours is underdeveloped. People are supported in making decisions about their everyday lives, and are involved in how the home runs. Risks generally are identified, and assessed in such a way as to encourage safe participation in a range of activities. EVIDENCE: For each person living at CARE there was a care plan that they had signed. Examples seen showed they were reviewed six-monthly and there was evidence of changes and additions to them, showing they were working documents. The plans described people’s preferences about personal care and morning and evening routines, together with detail of how the person arranged aspects of life such as laundry, cleaning, activities and interests, and what support was needed. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 13 Plans included communication guidance. For new and agency staff, houses had good information that showed the priority support needs of individuals, together with the main basic routines of the house. Two agency staff said they found CARE care plans up to date, comprehensive and easy to follow. Care plans gave insufficient alert to staff about certain behaviours that individuals could present. For some people, a clear behaviour management strategy would have been useful, to ensure a consistent response. This could be backed by better monitoring of incidents and responses, to inform ongoing review. Records in the home, and notifications of incidents to the Commission, showed that staff responded to incidents in person-centred terms and enabled effective debriefing. Incident sheets comprised of “details” and “action taken”. But they did not always contain details of final outcomes, or comment on how successful any intervention had been. The forms were supposed to be copied to individuals’ care records, but there was evidently a considerable time lag before this happened. For one person, the last filed incident record was from July 2007, but there had been a number of incidents since then. Improvements in recording would help in agreeing and reviewing behaviour management strategies. In addition to the care plans, people had a “person centred” plan that they kept in their own room. The aim of these plans was to support people to set goals they wished to achieve, and to put in place the things they would need to reach their goals. Every person had a key worker assigned to them. It was a key worker responsibility to develop the person centred plans. A day per month was put aside for this purpose, which could be used for planning work or for putting a planned event into action. A record of a person’s annual review with their care manager showed a number of goals had been achieved. The care manager wrote, “X talked about the things he’d been doing since the last review with the aid of photographs. His independence and living skills continue to go from strength to strength.” There was a strong sense of group identity within the houses. People confirmed they valued regular house meetings, where they could decide together such things as chore rotas and how to live alongside each other. Minutes of a recent meeting in one of the houses showed there had been discussion about a range of everyday issues, most of which were brought up by people living in the house. A recent discussion had been about answering the front door bell of the house. Meal times were also used as a natural venue at which conversation was promoted between people. All bedrooms had locks and people chose whether they wished to use them. They were able to choose whether to join in organised or spontaneous activities or trips. All people were supported in managing their own bank accounts. There were suitable arrangements for enabling them to have access to their money. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 14 A person said which bank he used, and that he could withdraw money at any time. Records were kept for all monies paid in or out of safe keeping in the houses, without extending to personal information about how people spent their money. There was information available about the availability of advocacy, and some people were active in an external self-advocacy group. People living at CARE had representatives on a management committee, to ensure residents’ views were heard at the highest levels. A total communication facilitator assisted with these meetings. There was also a monthly service user meeting, which staff attended only if invited, open to all people living at CARE. People’s care plans contained a range of risk assessments. These related to safety issues on the CARE site and in activities that individuals pursued. For one person, for example, there were specific assessments about horse riding and travelling independently on buses. These showed an approach to risk assessment as facilitating activities by managing identified risks, rather than to impede opportunity. In one of the houses there was an exercise bike, said to be well used. Individual use of this needed to be risk assessed. There was a tendency in some documentation, which was reflected in how people spoke, to use jargon in place of everyday language. For example, people routinely spoke about “self catering”, which simply meant going food shopping, and “PA” (personal allowance) was used in place of money. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 15 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): 11 – 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Varied activities give people opportunities to maintain leisure interests, to develop skills and to access the community. Relationships with families and friends are encouraged. People participate in everyday tasks and their rights are respected. A healthy diet is offered, with people being fully involved in choices and provision of meals. EVIDENCE: The service exists to promote personal development, both in the approach to care planning and living in the houses, and by provision of a range of day activities. These include horticulture, catering and hand crafts, with basic qualifications that people can aim for. Adding a job coach to the staff and making links with local colleges, has extended the potential for development, so people are not restricted to training and job opportunities on site. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 16 Some people are able to take advantage of the semi-independent flats in the bungalows, extending skills in managing their lives and relationships. Sometimes people are able to move on to supported living arrangements, provided elsewhere by CARE or by other providers. The development of person centred planning (PCP) meant people were supported to identify activities they wanted to do. Apart from their monthly PCP day with their key worker, they also had a “work/life balance day” each month in which to pursue interests and activities. Many people were able to access the local community alone, for example to go shopping. All were encouraged to make use of bus passes. One person’s review showed they had joined a book club, to learn how to use a public library and to integrate enjoyment of books into their life. They spoke about the success of this. They were now going independently by bus to the library, and they showed the books currently borrowed. Another person had joined a sports club and been on a holiday with the club. Internet access was supported to help people research information towards pursuing PCP aims. Records of activities, and talking with people, showed a variety of trips and entertainments were enjoyed. Some people regularly attended a Gateway club. Some had been on theatre trips, and two people were planning a trip to a spa. A person described going to watch football matches. However, feedback from staff and people living at CARE suggested that leisure activities were dependent on staff availability, especially at weekends. Holiday provision was co-ordinated by one member of staff. A number of choices, all to be in Britain in 2008, were offered. People had to save towards their holidays. The company paid for staff to accompany them. For keeping in touch with friends and family, each bungalow had a small private room with pay phone. Some people had mobile phones. Many people spent some of their holiday times with their families, and days or weekends out with families were not uncommon. Two people spoke of the ease of having family members to visit them. There was evidence of specific support to some people in managing relationships, including access to sexual health education. A current goal someone was working on through PCP was arranging to have a friend visit for tea. People were able to keep small pets. Through house meetings, and informally over the meal tables, people agreed on division of chores in the home. Pictorial aids were put on notice boards to remind people of what was agreed. People were supported to keep their rooms and clothes clean. In the houses, people made constant choices between enjoying the privacy and resources of their rooms, and mixing with one or more of their fellow residents and with staff. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 17 As a result of their person centred planning, one person was using some charts they had devised with their key worker to monitor how they were meeting aims in healthy living, making choices and community access. All respondents to the postal survey of service users said they made decisions each day about what they did, and could do what they wished at different times of day. One person added that their one-to-one worker helped them do what they wanted. Two people added that staff shortage at weekends could affect what they could do, especially off site. Lunches that the inspector shared were good quality and the kitchen/diners were conducive to a positive atmosphere. People said they always ate well. They could choose alternatives, for example, in one house the lunch was a homemade soup, but two people chose cheese on toast instead. Each house had weekly menu planning meetings and everyone was involved at different times in helping staff with food shopping. A nutritionist’s advice on menu planning had been obtained in 2007. In one of the houses, the shopping list was produced pictorially on computer and provided prompts to meeting basic agreed criteria, such as “five a day”. Pictorial ingredients cards helped people indicate things they really would or would not like included in their meals. Staff took primary responsibility for producing meals, but people living in the houses had plentiful opportunities to be involved. Those living in the flats could choose to what extent they catered for themselves. People could make drinks and snacks at any time, although some control had become necessary over late night snacking. A person had an intolerance that restricted their diet; they said they had never had any problems of availability of suitable foods that they liked, as the shopping list for their house included specialist items from a health food shop. A central canteen, where lunches were formerly served, had been withdrawn from use, so people now returned to their respective houses for lunches. This was an appropriate way of transferring some responsibility back to people and reducing a risk of institutional provision, although it was not popular with most people that were spoken with. There was scope for increasing choice for people at this time of day, perhaps by taking a packed lunch to day activity, or inviting friends from a different house to lunch. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 18 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 – 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides personal support in line with people’s preferences and needs. There are good links and systems to ensure physical and emotional health needs are met. People are protected by the home’s medication procedures. EVIDENCE: Care plans set out people’s preferred ways of being supported with personal care, where this was a need. One man’s care plan showed that he would choose daily whether to have a wet or electric shave. The same person had indicated through care planning review that where possible he wished for personal care support from male staff, and this had become part of the care plan. For another person, who was self-caring, person centred planning had been used as a means to encourage them in actively planning how best to recognise and meet their grooming and health needs. They had been supported to obtain GP advice, and had a goal to follow that advice to exercise and lose weight. They had been supported to gain further advice from a physiotherapist and a gym. It was apparent that people were supported to take a pride in appearance and to be themselves in terms of how they dressed.
CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 19 Most people were registered with the same GP practice and all were enabled to have annual medical checks. There was support to ensure regular keeping of optician and dentist appointments. The service had good availability of first aid. It was noted that the service had the Department of Health “Heatwave” guidance, and a service hot weather plan had been developed in response. Specific individual health needs and conditions, such as diabetes and epilepsy, were recognised in individual care plans, with provision for monitoring or other special measures as appropriate. Records and discussions showed that emotional needs were recognised and outside professional help obtained, often with the help of care managers. For some people, one-to-one staffing at certain times during the week gave them the chance to address emotional issues with people that were not part of their everyday staff group. One of the home managers had overall responsibility for implementation of the medicines policy in all the houses. All support staff received medication administration training as part of their induction, and training by the supplying pharmacy in use of their monitored dosage system (blister pack system). They “shadowed” experienced staff for some time before taking on responsibility of administering medicines. However, the responsible home manager was in discussion with the training manager about how to set up renewal training so staff could revisit this area, to reduce the risk of complacency and to keep people up to date with best practice. This should be seen as a priority task. Storage of medicines in all the houses was good, as was the keeping of Medicines Administration Record (MAR) charts. All handwritten additions were double-signed, as recommended at the previous inspection. Prescriptions were photocopied and the contents of each blister pack were checked against the prescription, the label and the MAR chart. In front of each person’s MAR sheet was a page with their picture, to guard against medicines being given to the wrong person. This page also contained a list of what medicines the person took. It would be helpful to staff if this list were expanded, to remind them and the people receiving the medicines what each is taken for. Patient information leaflets were kept, so staff could quickly access details such as risk of side effects. Examples were seen in care plans of guidance to the administration of ‘as needed’ medicines, and preferred individual ways of taking a medicine. In line with a recommendation at the previous inspection, people concerned had signed to indicate they had requested particular arrangements. Letters on file showed that agreement was being sought from the GP practice and the supplying pharmacy about ‘homely medicines’ that could be kept in stock, for example for relief of colds or stomach upsets. This was also a recommendation at the previous inspection and had been receiving active attention for some time.
CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 20 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. There are appropriate procedures to receive and act on complaints and to protect people from harm. EVIDENCE: The company’s formal complaints procedure was on display in the houses and was distributed in an accessible format to all people using the service. There were reminders to people through meetings of how to use the process, whilst people were asked to voice any concerns or complaints at any time to any staff. People spoken with said they knew how to make a complaint. Kay Rudge said the provision of literature about the complaints procedure was being looked at within the overall review of accessible information. Three complaints that had been received in 2007 had been responded to by appropriate letters and arranging meetings to discuss issues. Apologies had been made where indicated by complaint investigation. Regular meetings for relatives and for people that live at CARE were seen as important ways of allowing issues to be aired and worked on before becoming subject of complaints. Equally the constant communication within the houses and workshops, and one-to-one and key work, gave people good opportunities to raise and discuss any dissatisfaction in a natural way. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 21 In the postal survey of people living at CARE, everyone indicated they knew who to speak to if they were not happy. One person made additional reference to the management committee. Another added; “I would tell staff if I was unhappy. I’m asked every day if I am happy.” Training in abuse awareness and understanding safeguarding processes was a part of induction, and was renewed for all staff every two years. There was experience in the service of referring matters to local inter-agency procedures. Sometimes, individuals were identified as posing a danger to themselves or others. There was evidence of liaison with outside agencies in such situations. Staff received training in limited physical intervention. The training was proactive. It emphasised the importance of making sure environmental and activity factors were in place to reduce the likelihood of a person displaying behaviours and recognised that behaviours are a form of communication. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 22 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 home provides a homely environment, maintained and kept clean to a high standard. EVIDENCE: All the houses presented well in terms of décor, quality of furniture and cleanliness. People left personal items in communal areas, which added to a generally homelike feel. Outside lawn areas had furniture for use in good weather. Some bathrooms were somewhat plain, although partly because of the good practice whereby people kept all their toiletries and towels in their rooms, to avoid compromise of hygiene. All the bedrooms, with the exception of the semi-independent flats, were of a similar size. Many people said they liked their rooms, and one person said he would prefer a larger room. People that lived in the flats were very satisfied with their accommodation, which provided them with en-suite facilities and a kitchenette. All bedrooms were lockable, but doors had a built-in means of gaining entry to a room in an emergency.
CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 23 The entrance to each of the houses was via a wide hallway. Although these areas were furnished, they had an impersonal and empty feel, and in some of the houses it was said that people made little use of this space. There may be ways of making these hallways appear more inviting or useful. People living in the houses helped with domestic tasks in communal areas, such as vacuum cleaning. They received one-to-one support each week for cleaning and tidying their own rooms. Cupboards used to store cleaning materials and equipment, including protective gloves, were well organised. The service has been represented at infection control events run locally by the Health Protection Agency for regulated services. Houses had maintenance request books. These showed that any defects notified received swift attention, contrasting with the situation reported at the previous inspection. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 24 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 & 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by competent, trained staff, who experience regular supervision and are supported by an employer committed to staff development. Recruitment practices ensure people are protected from being cared for by unsuitable staff. EVIDENCE: Each of the houses had its own team of support workers, headed by a house manager and assistant manager. Kay Rudge spoke of difficulties in recruiting sufficient staff over the previous year. The company had put some measures in place to try to address this. Surveys returned by staff, service users and relatives showed a degree of anxiety about maintaining staffing levels, particularly at weekends when people would like to go out more. Meanwhile there was reliance on staff working voluntary overtime, and on use of agency staff, to maintain a minimum of two support staff in each house at peak times. (Specific one-to-one support was always additional to house staffing). CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 25 Fortunately the six agency staff commonly used, worked regularly in each of the houses at CARE, and so people experienced continuity of care. Two agency workers each confirmed familiarity with care plans in all the houses and with the service’s policies and procedures. They felt they knew people’s needs well. Good working relationships were in evidence. There had been some recruitment. Three newly appointed support workers were undertaking induction at the time of this inspection. This began with a two-week period mainly with the training co-ordinator. This period was used to introduce people to the service’s policies and procedures, and to provide training in areas such as safeguarding and manual handling. An induction record was used, in line with recognised “core induction standards” for working in care. The process was underpinned by small group discussions and written tests. New staff had some supervised time with people that lived in the houses. In their first six months of working at CARE they completed the Learning Disability Qualification (LDQ), for which the service is an accredited City & Guilds centre. Their progress was reviewed after three months. The service had experience of discontinuing a probationary period. People then went on to attain the National Vocational Qualification (NVQ) in care at level 2, by the end of their second year. This expectation was in their job description. Assistant house managers were expected to do NVQ level 3 in supervisory management. House managers worked towards NVQ level 4. One member of staff spoke positively of their experience of a modern apprenticeship with the service. A partnership with a local college was being arranged to support two new apprenticeships. These would commence with six months experience in the workshops, before introducing the young people into supervised support work in the houses. Recruitment records were examined in respect of the six most recently recruited staff. For each person there was an application form, at least two references and a health assessment. Criminal Records Bureau (CRB) disclosures were either on file, or had been applied for in the case of people who had just commenced induction. In the latter case, there was documentary evidence that the people were not on the Protection of Vulnerable Adults (POVA) list as unfit to work with vulnerable people, and they would not be working unsupervised with vulnerable people until the full CRB disclosure had been received. A relative added to their survey form, “There appears to be a rigorous recruiting procedure and no-one is selected just to fill a vacancy; they have to be suitable.” Interview records were kept, showing a standard set of questions were used and scored. They also showed that people that lived in the houses were directly involved in the interview process. The job coach had given them guidance and training on how to contribute to the interviews. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 26 A written record was made of how they perceived people’s responses to interview. For example, a person was noted as having made little eye contact with the people on the interview panel. A staff member added to a survey form, “When interviewing for staff the service users play a major role in choosing who gets employed.” The training co-ordinator demonstrated an efficient computer system that allowed her to access the training record and plan for any member of staff. Refresher training in any of the mandatory training areas could be swiftly set up. Special interest training that had been arranged included epilepsy and sexuality and relationships. A link had been made with a specialist dementia agency with a view to developing training. There was ample room for the administration and delivery of training. Staff that were spoken with saw provision of training as a strength of the service. In a postal survey, a member of staff added, “I think training and up to date information are excellent.” Another wrote, “The service provides a great induction and training programme for staff to enable them to do their job.” The training manual for house managers included content on supervision and appraisal of staff. One house manager showed examples of supervision records. Supervision was regarded as a priority monthly task and was recorded consistently. A support worker in another of the houses confirmed receipt of monthly supervision and found it supportive. It always included consideration of the worker’s responsibilities as a key worker, and of the current needs of all people living in the house where they worked. Minutes of staff meetings showed they also were regular and included updating information regarding all people that lived in the house. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 27 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, 38, 39, 41 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The nature of leadership and direction means people benefit from a well run home. Quality assurance systems include obtaining the views of service users and their supporters to monitor and improve the service. There are systems in place to identify and promote the health and safety needs of residents and staff. The reliability of records can be compromised by inattention to detail. EVIDENCE: At the time of this inspection, the registered manager of the service had been suspended as a result of operation of the company’s grievance procedure; she has since resigned. Kay Rudge, regional manager, who is based at CARE Wiltshire in any case and is well known to staff and people who live there, has provided continuity of management. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 28 There is also a large measure of delegation of duties, such as staff supervision and medications oversight, to the individual house managers, who are trained to the level of Registered Managers Award. So in the short term the loss of the service manager is not critical. Kay Rudge said that the grievance against the former manager did not have implications for the wellbeing of people that lived at CARE. Kay Rudge was maintaining a pattern of weekly meetings for house managers and assistant managers. They were affected by the recruitment difficulties, and assistant managers ‘acting up’ were covering two house manager posts. Minutes showed that general staff meetings, for all staff on the site, were held two-monthly. They began with feedback on issues from the service user meetings, to ensure those received priority consideration. There was also a quarterly forum for relatives. Minutes showed this was very much a two-way exchange of information and ideas. People living in the houses had representatives on a management committee with Kay Rudge. A formal system of gaining quality assurance feedback from all stakeholders had been dropped as too onerous, but a new, independently run quality audit system was to begin in April 2008, to inform developmental planning. A range of changes in the service were under consideration. There was evidence of ongoing consultation with families and contracting authorities. One person had delegated oversight of provision for health and safety on the site. There were internal monitoring systems and monthly health and safety meetings, with contributions from people that lived in the houses. For example, it had been identified that there was more traffic on the site’s roads and a zebra crossing had been installed at the suggestion of people living there. The service had an emergency plan that was kept to hand in all the staff sleep-in rooms. This was revisited periodically with staff through staff meetings. With regard to records, it was noted that correspondence and notes received in the houses from elsewhere were not date-stamped. This meant the history of some items could not be determined, so it was not possible to know if they were current or not. This led to a danger of certain notes remaining on file, and seemingly relevant to a person’s care arrangements, long after they should have been archived. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 X 34 4 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 4 4 2 X LIFESTYLES Standard No Score 11 4 12 3 13 3 14 3 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X 2 3 X CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? NO 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 YA9 Regulation 13 (4)(b) Requirement Any potentially hazardous equipment provided by the service must be subject to risk assessment. Timescale for action 30/06/08 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 YA6 YA23 Good Practice Recommendations Ensure behavioural incidents are fully recorded to allow for analysis, and for creation of behaviour strategies where appropriate. Avoid use of institutional terminology when referring to every day activities. Consider ways of making lunch time provision more flexible for service users. Add information to individual medicines information sheets so people are informed about the purpose of medicines in use.
DS0000028267.V359723.R01.S.doc Version 5.2 Page 31 2. 3. 4. YA8 YA17 YA20 CARE Wiltshire 5. 6. YA24 YA41 Consider ways of making the houses’ entrance halls more welcoming and usable. Ensure all documents in people’s individual records are signed and dated, and removed or archived when they become out of date. CARE Wiltshire DS0000028267.V359723.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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
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