Inspection on 28/11/07 for Church Street Short Breaks

This inspection was carried out on 28th November 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Church Street Short Breaks 17/11/08

Church Street Short Breaks 09/11/06

Church Street Short Breaks 25/01/06

Church Street Short Breaks 23/05/05

Church Street Short Breaks 16/11/04

Church Street Short Breaks 22/05/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Church Street Short Breaks 88 Church Street Golborne Wigan Greater Manchester WA3 3TW Lead Inspector Sarah Tomlinson Unannounced Inspection 28th November 2007 10.00 Church Street Short Breaks DS0000005730.V355385.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 Church Street Short Breaks DS0000005730.V355385.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. Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church Street Short Breaks Address 88 Church Street Golborne Wigan Greater Manchester WA3 3TW 01942 272079 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) Wigan Council Social Services Department (vacant) Care Home 4 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (4) of places Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered for a maximum of 4 service users to include:up to 4 service users in the category of LD (Learning Disability) up to 4 service users in the category of LD(E) (Learning Disability over 65 years of age) The service should at all times employ a suitably qualified and experienced manager who is registered with the CSCI The Registered Manager must spend a proportion of their working hours each week on site to have a clear presence in the home, to oversee the running of the home, and supervision of care staff on the premises, to include weekends and times when service users are present in the home. This must be reflected on records maintained in the premises. 9th November 2006 2. 3. Date of last inspection Brief Description of the Service: 88 Church Street is a small care home, owned by Wigan council and run by its Social Services department. It provides a short-term break (respite) service for up to 4 adults with a learning disability. People usually stay during the week (Monday to Thursday) or for a weekend (Friday to Sunday). The home is a small, purpose built bungalow in Golborne, close to local shops and amenities. It is on a main road, with a grassed front garden and an enclosed patio and garden area to the rear. There is a small amount of parking at the back, reached by an un-adopted road. There are 4 single bedrooms, each with a wash hand basin. There is a combined lounge and dining room, a kitchen, an assisted bathroom and an assisted shower room. During the week, the home is not occupied between 10.30am and 3pm (as service users are out and staff are not working). The manager is based at a separate office. The cost of staying at the home ranges from nothing to £69.31 per night. Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector visited without telling anyone she was going to come. The visit lasted 8 hours. We met 4 people who used the service and 4 care workers. The acting manager was on a day off, so we met with her manager instead (we telephoned the acting manager the next day). During the visit we watched how staff cared for service users, looked around the building and looked at some of the records. Before the inspection, we had asked the acting manager to complete a form called an Annual Quality Assurance Assessment (AQAA), to tell us what they feel they do well and what they need to do better. This helps us decide if the management of the home sees the service they provide the same way we do. We felt this form was completed honestly. Before the inspection, we also sent surveys to people who use the service and their families. We had 9 replies and their views are included in this report. We telephoned one relative to talk more about some concerns they had. The home did not currently have a manager. The previous manager, Christopher Parr, had left earlier in the year. Tina Knight was the temporary, acting manager. A new manager had just been appointed and was due to start in December 2008 (they will then have to apply to us to become the registered manager). What the service does well: What has improved since the last inspection? To find out what each service user thinks about the home, they are going to have a review meeting every 6 months. Information from this will be in pictures and easy to read words. Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 6 To help share information about service users and better support them, staff had started going to outside reviews. To keep the home looking nice, the shower room, hallway and lounge/dining area had been redecorated. To help work get done, the acting manager had organised some flexible time for staff. 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. Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there was a lot of support for new service users, their safety and wellbeing and that of existing service users was at risk, as more consideration was needed regarding their compatibility. EVIDENCE: Information about the home was provided in a Statement of Purpose and a Service User’s Guide. Good practice was noted as the Service User’s Guide was provided in an easy to read/pictorial format, more suited to the needs of service users. Our contact details on pages 17 and 19 of this Guide needed updating, plus the statement that we inspect the home twice a year. Some minor changes were required to the Statement of Purpose - the Responsible Individual should be identified by name, with their contact details, relevant qualifications and experience included. The complaints section should be amended to explain a complainant could contact us at any stage of their complaint (with our up to date contact details included). There was no statement about the aims, objectives or philosophy of the home. A description of the service (e.g. explaining what a short break service is) and the number of places was also missing. It was also given to families of prospective service Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 9 users. We felt its style was not easy for families to read and it did not provide them with sufficient practical information (e.g. who can refer; length and frequency of stay; booking and payment procedures; medication procedures; cooking and laundry arrangements). We were impressed with the settling in (‘getting to know you’) process provided to new service users. It was personalised, with consideration given to individual needs, concerns and anxieties of the prospective service user and their family. After receiving a comprehensive needs assessment, a key worker was allocated. They visited the prospective service user and their family at their home, supported them to visit Church Street and also visited their day centre. Prospective service users usually then came for 4 ‘tea visits’, before their first overnight stay. However, whilst staff gave details, there was no written record of this process for a new service user. Also, as their referral information was from January 2007, a record of the assessment and settling process would show whether their needs had changed during the interim 9 months. We looked at the compatibility of service users staying at the same time (with regard to physical space available and also personalities). Many had complex needs and behaviours that could challenge the service. We were told compatibility was considered but the service also tried to accommodate families’ requests for certain respite dates. We felt not enough regard was always given to ensuring the assessed needs of each service user were being met - with places being offered when it was not appropriate to do so. During the inspection, the small communal lounge/dining area prevented 2 service users from both safely being on the floor at the same time, requiring 1 service user to stay in their wheelchair. Also, a service user who did not like being near wheelchair users, stayed at the same time as a person who used a wheelchair. Good practice was noted as service agreements were provided in easy to read/pictorial formats. However, individual agreements did not say how much it actually cost to stay and who would be paying this fee (our contact details also needed updating). Once a service user had stayed, a courtesy call was made to their family before their next stay to confirm care needs. To help track care needs at different admissions, we advised a simple record of admission and discharge dates (including the original admission date) should be kept in the front of each service user’s file. A copy of our most recent inspection report was on the hallway cupboard. We advised the registration certificate needed replacing with an updated one we had sent on 10th October 2007. Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Gaps in care records placed service users at risk of their needs not being fully understood or met. EVIDENCE: We looked at 5 care files. There was a lot of detailed and personalised information about support needs, including preferred daily routines and how service users liked their care to be provided. Some of this was reviewed regularly. Good practice was noted, as considerable work had recently been done regarding the use of bed rails for one service user, with clear awareness of potential risks. Further good practice was noted, as a new pictorial/easy to read review form was being introduced (to ensure a review that focused solely on service users’ stay at the home). As part of this, service users will identify activities they would like to do whilst at the home. We discussed how this will Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 11 be followed up and recorded. Good practice was also noted, as key workers were now attending external reviews for ‘their’ service users. However, we also had concerns about care files. For two current service users, risk assessment information was missing. We were told it had probably been taken as part of a complaint investigation. We advised such information must be on site for staff to access. It should only leave the premises for a very short period (being returned the same day). If needed for longer, a photocopy should be made and the original document left in the care file. Also, although both risk assessments were supplied to us shortly after the inspection, there were no details about one service user’s physical aggression to others (including 2 previous incidents towards staff), nor any guidance about how to reduce or manage this risk. There were guidelines from their day service but these were specific to the day centre and were a year old. We were also concerned one of the incident forms about the physical aggression towards a staff member could not be found. In addition, we had not been notified of either of these serious incidents. Another new service user’s file only had a copy of their day centre risk assessment (from 1/07), which identified high-risk issues such as ‘aggression to others’. The brief strategies for managing and reducing these risks were again specific to the day centre. This service user also had epilepsy but there were no details about the frequency, type of seizures or support required. We found some information difficult to find. ‘Help notes’ (care plans) were not always dated or signed. There was also no identified place to show when they were reviewed (or what information, if any, had been added or updated as part of a review). It was also unclear what records were the home’s and what were from another service. The front sheet was unclear about who the service user lived with and did not always identify their relationship to people named. Photographs were generally in place, albeit ones displayed on 3rd party information. A lot of information was written in daily diary sheets about what service users ate. However, this was already recorded in a menu book. We advised it should only be repeated if there were concerns about an individual service user (which were not being separately recorded on fluid and food intake charts). More personalised information would better reflect the care given by staff. Staff knew service users (and their families) well and were able to describe their support needs, care preferences, likes and dislikes. This generally matched with information in care records, although as noted above there were serious gaps. Staff described how they helped service users make decisions. In view of the recently introduced Mental Capacity Act (2005), staff should consider how they demonstrate this (e.g. by what they write in diary sheets). At the last inspection we had recommended an independent advocate became involved. This had not happened. Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 12 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, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users took part in activities that reflected their choices and capabilities, although those inside the home were restricted due to the limited space. EVIDENCE: During weekdays, service users attended a range of educational, therapeutic and social activities. These were away from the home (at colleges and day centres). Service users left the home by late morning and returned late afternoon (the home was empty and not staffed between 10.30am and 3.00pm). Staff were available during evenings and weekends to support service users outside the home (e.g. visiting the local pub, going out for a walk, shopping or to the cinema). Some service users were very busy during the week and Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 13 preferred to rest and do very little during their stay. We advised such wishes were clearly recorded and regularly reviewed. Good practice was noted, as strong links were maintained with families. As noted previously, courtesy calls were made before and sometimes after each stay, with staff checking current care needs and any issues they might need to be aware of. The home was often busy, particularly at weekends, with usually 4 service users and up to 4 staff present. As noted previously, communal space did restrict some service users ability to engage in activities they enjoyed (e.g. being on the floor). Service users could chose to be alone in their bedroom. However, this was difficult for those service users who required constant support and supervision from staff. Although some service users helped, it was the responsibility of staff to prepare the main evening meal. Service users used to accompany staff food shopping, although due to transport difficulties staff now did this alone. With regard to choice, staff made meals that reflected the likes and dislikes of service users. Good practice was noted, as staff were expected to eat with service users. Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 14 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Support needs were met, promoting good health and personalised care. EVIDENCE: Due to their complex and specialised needs most service users were unable to tell us what it was like to stay at the home. However, relationships between staff and service users seemed warm, friendly, caring and supportive. Staff listened to service users, treated them with courtesy and supported them to make choices. As noted previously, there were detailed records about how each service user liked their care to be given. Staff had a good understanding of this information, giving examples of service users’ preferred routines. Four survey replies from relatives felt service users were treated well. One relative said “they always show concern for [my relative’s] wellbeing and health, [my relative] is very happy to go into the house … and always enjoys it when they are there”. Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 15 If needed, service users were supported to access healthcare services (e.g. their GP). To enable this information to be tracked over time, we advised a separate record be kept (e.g. detailing who was seen, when, the reason why and the outcome). With regard to medication, families completed an information sheet for each visit, detailing any current medicines. The home should regularly confirm this information with the prescribing GP. There was a clear audit trail showing medicines received, administered and any returned to the service user’s family. Good practice was noted, as a balance of medicines received and any returned was kept. However, we advised Wigan MBC’s policy of also having a running balance was unnecessary (this is only needed for controlled drugs). Good practice was also noted, as the handwritten Medicine Administration Record sheets were signed, checked and countersigned. Medicines were stored safely, although storage space was extremely limited. We advised more was needed, as all care homes should now have a controlled drug cupboard. There were instructions for a new service user’s medicines to be crushed and hidden in food. If covert administration is to take place (when the service user lacks capacity to consent and the medicine is essential to their health and wellbeing), the home must have clear documented permission from the service user’s GP and documented discussion with their pharmacist and involved professionals. We also discussed the practice of returning unused medication (and money) in service users’ luggage. We were told all day centres used by service users were aware of the need to keep their bags locked away. Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 16 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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst arrangements were in place for protecting service users from abuse or harm and for taking concerns seriously, service users were put at risk by recording and reporting procedures not being properly followed. EVIDENCE: Information about what to do if a service user (or their family) wished to complain was in the easy to read/pictorial Service User’s Guide. However, there was not a copy displayed in the home, which we advised should be available (e.g. on a covered service users’ notice board). Survey replies confirmed families generally knew how to raise any concerns they might have, although one said they did not. We were concerned the complaints record book was unavailable. We were told it had been taken as part of an investigation into a current complaint. We advised it should not leave the premises, unless for a short period. If needed for a prolonged investigation, a photocopy should be made and the original document left in the home. We were told that apart from the current complaint, no others had been made since the last inspection. We telephoned one relative who had raised some concerns in their survey reply. With their permission, these were passed to the home for them to formally investigate. Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 17 Small amounts of money were often held on service users’ behalf. These were being stored safely and securely, with appropriate records kept. A second record was kept in the admission and discharge record book. We advised such duplication was unnecessary. Two cash balances were checked at random and found to be correct (although one had not been signed out). Good practice was noted, as staff were currently undertaking formal Safeguarding Alert training. As noted previously, we had concerns that recording and reporting procedures were not always followed regarding physical aggression displayed by service users. We were also concerned that a Safeguarding Alert/Adult Protection issue (that had been investigated appropriately, with no abuse found) had not been reported to us. Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home provided an attractive, comfortable and safe place to stay, more communal space was needed to meet the specialist needs of some service users. EVIDENCE: The home was comfortable, bright and welcoming. There was a good standard of décor and furnishings, which were domestic and ordinary in style. Although one survey reply from a relative said the home could be “more homely and cheerful”. Although the kitchen was not designed for wheelchair users, there was a range of adaptations in the home, including lowered light switches, raised sockets, an assisted bathroom and an assisted shower room. Two of the 4 bedrooms had rise and fall beds, and one had a double bed. There was a large padded Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 19 headboard in one bedroom, with another about to be fitted. There was level access to both the front and rear of the home. One survey reply from a relative, raised concerns about security and the appearance of the area to the back of the home. The maintenance of the unadopted road leading to the back was the shared responsibility of all surrounding neighbours. We were told the public did leave rubbish (e.g. mattresses) at the back, but staff arranged for its urgent removal. Tall fencing surrounded the home at the back, with lockable gates, a burglar alarm and sensor lights. There had been no burglaries. At the last inspection we had asked the assisted shower room was redecorated. This had been done, as had the hallway and lounge/dining area. Discreet door alarms had also been fitted to bedroom doors to alert staff when a bedroom door was opened. We were told these were only used with certain service users (which should be documented in care files). There was no office. Staff had a sleep-in room, with very limited space. There was a large, lockable cupboard in the hallway for service users’ files. Several minor issues were identified at this inspection – some bedroom curtains were hanging off (these were about to be replaced by new poles); the chest of drawers in bedrooms 1 and 4 were worn and needed replacing or revarnishing; all the vanity units were looking ‘tired’ (the one in bedroom 2 was very worn and unsightly); bedrooms 3 and 4 both had two televisions, reducing available space; and lockable storage space was needed in bedrooms 2 and 3. Bedrooms would also benefit from towel rails for service users. With regard to communal space, as noted previously, the small lounge/dining area could become cramp, with limited usable floor space for service users. A bid had been submitted for a large conservatory to be built. The laminate flooring in the lounge/dining area was due to be replaced, for the comfort of those service users who spent time on the floor. We found the home clean and tidy. Care staff had some domestic duties, with a cleaner also working 2 hours each evening. Some minor issues were noted the hallway carpet was stained outside bedroom 2; bedroom 1 smelled musty; soap dispensers and paper towel holders (for staff use) were missing from bedrooms; the shower room soap dispenser and toilet flush were faulty. And against infection control guidance, communal hand towels were in the bathroom and shower room (paper towel dispensers were empty). Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst good recruitment practices and staffing levels protected service users, gaps in basic training did not. An increased management or supervisory presence during evenings and weekends would enhance this further. EVIDENCE: On the day of the inspection enough staff were on duty to meet the needs of the service users. There was a small, stable staff team - 7 day and 3 night staff. Previous rotas showed staffing levels were good. A minimum of 2 staff were on duty during the day (7.30am – 10.30am; 3pm – 11pm). This would rise to 4 depending on the service users staying. At weekends, the home was staffed all day. There was also a minimum of 2 staff at night – 1 day carer slept in, whilst a night carer worked a ‘waking night’ (this number would increase depending on the needs of the service users). The manager was based in a separate building (approximately 10 minutes away by car). Within their core hours, the acting manger had recently introduced 7 ‘flexi’ hours for each staff member. Staff felt this was working well as it enabled Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 21 them to carry out tasks outside their usual shift patterns and work around the busy times of the service (e.g. attending external reviews, updating care records, preparing the Friday meal). Regular staff meetings and individual supervisions were held. No appraisals had been carried out since the last inspection. The home had been identified to pilot a new system that was due to be introduced. We discussed how staff shared information, as day staff arrived on shift to an empty building (with no handover). Staff said they shared information with each other and a communication book was also used. Good practice was noted, as readers were referred to individual files for personal and confidential information about service users. On previous visits we had had concerns about the support and supervision provided to staff (as the manager was based off site). At this inspection, we received positive feedback from staff who felt well supported by the acting manager (who usually visited once or twice a day). However, we advised that due to the specialist needs of service users and the absence of senior care staff, the manager should also regularly work along side staff during evening and weekend shifts (to provide support and monitor care practices). The manager’s hours, particularly when working in the home, should be recorded on the rota. With regard to training, good practice was noted, as 9 of the 10 staff had attained an NVQ qualification, with the 10th team member currently undertaking the level 2 award. Individual training files were not available. After the inspection, the acting manager provided some information. Good practice was noted, as the new starter had been able to shadow shifts before starting. They had completed an induction with the acting manager. However, many items had been signed off on the new starter’s first day. An induction programme should be robust and detailed, with start and finish dates included. Each item should not be signed off until the new starter and their supervisor feels they are confident and competent. Although the acting manager had met with the new starter, they had not worked alongside them for a shift, with no record of induction tasks being allocated to another staff member. Training records used by the home were unclear as they included training applied for but not attended. Existing staff had received a range of previous training, including moving and handling, food safety, autism spectrum disorder, challenging behaviour and physical intervention training. However, we were concerned to no recent moving and handling or fire safety refresher training. Annual refresher training about challenging behaviour and physical intervention should also be considered. Of the 3 staff records we looked at, only 1 or 2 courses had been attended. Although a team-building day was about to take place, we expect staff to attend at least 5 paid training and development days (pro rata) each year. At the last inspection, we had Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 22 recommended staff received service specific training in retts syndrome and diabetes (reflecting the needs of service users). This had not been arranged. Formal, off site training sessions should be complemented by internal training, which could be a regular part of staff meetings (with attendance, including the length of the session, recorded on individual staff training records). Staff recruitment records were kept centrally at Wigan Social Services. We had looked at a sample of these during a separate inspection in June 2007. Information seen included a completed application with full employment history, 2 written references, health information, contracts and criminal record checks. These details had been gathered prior to new staff commencing their employment, ensuring that the people who used the service were protected. Church Street Short Breaks DS0000005730.V355385.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, 41 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The new manager will need to review some practices in the home. Safety matters are not always dealt with appropriately, which potentially places service users and staff at risk. EVIDENCE: The home was currently without a permanent manager. The previous manager, Christopher Parr, had left earlier in the year. Tina Knight was the acting manager. A new permanent manager, Mohammed Asafa, had just been appointed and would be starting in December 2007. Once in post, he will need to apply for registration with us. Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 24 With regard to how the home monitored the quality of its service, whilst service users were now being asked for their views, surveys should also be sent to families, stakeholders (e.g. day centres, community health professionals) and the staff team. The results from these should be collated and published, with action plans developed. At the last inspection we also had concerns the monthly unannounced, quality monitoring visits were not done regularly. Although we were told these were now being done, we were not receiving copies of the accompanying reports. As mentioned previously, we had concerns about missing records. Whilst Wigan Social Services complaints department had taken most (although one incident report could not be found and some risk information was just not in place), there was no list of what they had actually taken. Records should have remained at the home or the office base, particularly those documenting current service users’ needs. Before the inspection, the home had provided details of safety and maintenance checks carried out. We also looked at some records during the inspection. These showed up to date safety checks for hoists and fire safety equipment. However, we were concerned the fire alarm was not tested weekly and the means of escape was not checked at all. To encourage familiarity and confidence in the fire alarm system, we advised different staff should conduct the weekly fire test (rather than just the acting manager). At the last inspection we had required staff to attend regular fire drills. We were concerned no fire drills had been held. Portable electrical appliances had last been tested in October 2006. We expected an annual test for any appliances used with or by service users in the kitchen/wet areas. (After the inspection, we were told testing was due to be carried out in December 2007). There was also no record available regarding the soundness of the home’s electrical wiring system (NICEIC test). (After the inspection, we were told a test had been arranged for 17/12/07). Radiators were covered and could be individually controlled. We were told thermostatic mixer valves were fitted to all hot water outlets, including the shower and that bath and shower temperatures were also manually read. We advised current maintenance and safety certificates should be organised in one file. With regard to recording accidents, a combined form was now used for both accidents and incidents. As noted previously, we were concerned serious incidents were not linked back into risk assessments and help notes. Also, whilst ‘new’ serious incidents were monitored centrally by Social Services, we advised the home to introduce their own monthly audit (e.g. a ‘master sheet’). This would enable both ongoing and ‘new’ behaviours to be monitored, any patterns identified (with action taken to reduce or manage the risk). Church Street Short Breaks DS0000005730.V355385.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 2 2 3 3 2 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 X 28 2 29 3 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 X 2 X 2 2 x Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA3 Regulation 12 (1) (3) (4) (b) Requirement To ensure service users’ individual needs are met, they must only be offered a place when it is safe and appropriate to do so, with clear consideration given to who else will be staying at the home. Service agreements must be personalised, to ensure service users and their families receive clear, individualised fee information. To ensure the safety of service users and staff, care records must include all relevant information (and be of sufficient detail to guide staff). To ensure the safety of service users and staff, all serious incidents of physical aggression and any event that adversely affects the well-being or safety of any service user must be reported to CSCI without delay. To protect service users, any decision to alter and/or disguise DS0000005730.V355385.R01.S.doc Timescale for action 31/01/08 2 YA5 3 YA6 YA9 5 (1) (bb), 5A (2) (a) (i) (iii) (b), 5B (1) (2) (a) 15 (1) (2) (b) (c) 31/03/08 31/01/08 4 YA9 37 (1) (c) (e) (2) 31/01/08 5 YA20 12 (1) (3), 13 31/01/08 Church Street Short Breaks Version 5.2 Page 27 (2) medication must be discussed with all involved parties and documented. To ensure service users’ (and staff) safety, all staff must undertake annual moving and handling and fire safety training. 31/03/08 6 YA35 YA42 18 (1) (c) (i), 23 (4) (d) Section 11 of Care Standards Act 2000 26 (5) (a) 7 YA37 To meet the home’s conditions of 31/03/08 registration, once in post, the new manager must submit his application to us for registration. To evidence the home’s quality monitoring system, copies of its monthly, unannounced quality monitoring visits reports must be sent to CSCI. All records required for the protection of service users and for the effective and efficient running of the home must be available at all times for inspection. To ensure service users’ and staff safety, • the fire alarm and means of escape must be checked each week (with records kept); a NICEIC safety test must be carried out and a copy of the certificate sent to CSCI; and in accordance with Wigan Social Services policy and taking into account the specialist needs of service users, staff must attend regular fire drills (previous requirement from last inspection). Version 5.2 Page 28 8 YA39 31/01/08 9 YA41 YA6 YA9 YA22 17 (1) (2) (3) (b) 31/01/08 10 YA42 23 (4) (c) (iii) (v) 31/01/08 • • Church Street Short Breaks DS0000005730.V355385.R01.S.doc 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 YA1 Good Practice Recommendations To ensure information about the home is correct, the Statement of Purpose should be updated (with regard to the points identified in the main body of this report). The Statement of Purpose should then be kept under review and revised where appropriate. CSCI and service users (or their families) should be notified of any revision within 28 days of any change. To ensure families of prospective service users get the information they need, the practice of giving them a Statement of Purpose should be reviewed. 2 3 YA4 YA6 YA9 To provide a record of support provided, details should be kept of the ‘getting to know you process’. To make care files easier to use, old information should be archived; 3rd party information should be distinguished from the home’s documents; and all the home’s records should be dated and signed. To support service users to make decisions, the home should consult with an advocacy service regarding how it can offer support (this was recommended at the last inspection). To better meet the specialist needs of service users, the communal space should be extended (or the admission of service users restricted when their needs for physical space cannot be met). To encourage service users and their families to raise any concerns, a copy of the easy to read/pictorial complaints procedure should be displayed in the home. And the Statement of Purpose amended to explain a complainant could contact us at any stage. DS0000005730.V355385.R01.S.doc Version 5.2 Page 29 4 YA8 5 YA14 YA3 YA28 6 YA22 Church Street Short Breaks 7 YA26 YA30 YA33 YA36 To provide an attractive, clean and safe place for service users to stay, the maintenance work identified in the main body of this report should be carried out. To enable service users to benefit from well-supported and supervised staff, the manager should regularly work evening and weekend shifts. The manager’s presence in the home should be recorded on the staff rota. 8 9 YA35 To guide and support new staff, a robust and detailed induction training record should be developed. To ensure service users’ specialist needs are met, the home should review what mandatory training staff are expected to complete (including annual refresher training). All staff should also complete 5 paid training and development days per year (pro rata). To further enhance the skills and knowledge of staff and better meet the specialist needs of residents, service specific teaching sessions should be provided. These should include training in specific conditions such as rett’s syndrome and diabetes (this was recommended at the last inspection). 10 YA39 To involve and gain the views of those using the service, satisfaction surveys should be sent to service users’ families, community stakeholders and staff (with the results publicised). Church Street Short Breaks DS0000005730.V355385.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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. 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