Inspection on 24/02/09 for Chy Colom

This inspection was carried out on 24th February 2009.

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

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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chy Colom 26/03/07

Chy Colom 03/03/06

Chy Colom 25/08/05

Similar services:

Clouds House

Closereach

Westcliffe House

Hilldales

Longreach

Chandos House

Cherry Orchards Camphill Community Ltd

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Chy Colom Chy Colom Agar Road Truro Cornwall TR1 1JU     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Ian Wright     Date: 2 4 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 33 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 33 Information about the care home Name of care home: Address: Chy Colom Agar Road Chy Colom Truro Cornwall TR1 1JU 01872262414 01872262355 chycolom@addaction.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Addaction Ltd Name of registered manager (if applicable) Mr Roland George Bence Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 past or present alcohol dependence past or present drug dependence Additional conditions: Date of last inspection Brief description of the care home Chy Colom is a detached property positioned in a residential area of Truro, close to the City Centre. There is a large garden at the front of the building and some car parking space. The registered provider is Addaction, a national charity providing support for people with substance misuse (i.e. drug and alcohol) problems. The registered manager Roland Bence has worked at the home for several years. The home has three floors; on the ground floor there is a large lounge, a dining room, a study room and a counselling room. The home is non-smoking but there is a facility at the back of the home for those who wish to smoke. The bedrooms are on the first and second floors; four of them are shared rooms. Access to these floors is by stairs only, wheelchair users or residents unable to climb stairs cannot be accommodated at Care Homes for Adults (18-65 years) Page 4 of 33 care home 11 Over 65 0 0 11 11 Brief description of the care home the home. The home operates a twelve-week rehabilitation programme. Residents are only accepted onto the programme following a very comprehensive assessment. Appropriately qualified and experienced staff work in the home. A copy of the inspection report is available in the home, and it is suggested a full copy of the report is requested from management or CSCI if required. The fee at the time of the inspection was £575. There are additional charges e.g. for newspapers etc. Care Homes for Adults (18-65 years) Page 5 of 33 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This key inspection took place in eight hours in one day. All the key standards were inspected. The methodology used for this inspection was: (1) To case track three people using the service. This included inspecting their records. (2) Discussing care practices with people using the service, staff and management. (3) Inspecting records and the care environment. (4) Surveying staff and people who use the service regarding their views. Other evidence gathered since the previous inspection, such as notifications received from the home (e.g. regarding any incidents which occurred), was used to help form the judgements made in the report. Care Homes for Adults (18-65 years) Page 6 of 33 Care Homes for Adults (18-65 years) Page 7 of 33 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 8 of 33 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 9 of 33 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information provided to people who use the service (e.g. regarding services offered) is good. For example all people who use the service (and /or their representatives ) receive a licence agreement when they move in. This ensures people are aware of their rights and responsibilities. Pre admission assessment procedures are to a high standard and ensure the registered persons check they can meet the persons needs before admission is arranged. Evidence: We inspected copies of the homes statement of purpose and service user guide. These contain satisfactory information about the service. People using the service are also supplied with a handbook which outlines the therapeutic programme. All this information should be helpful in assisting the people using the service to understand their rights and responsibilities during their stay. The registered provider has an excellent assessment procedure. For example prospective clients visit the service before admission is arranged, a full assessment is completed by staff, and supporting information is obtained from the sponsoring Care Homes for Adults (18-65 years) Page 10 of 33 Evidence: authority. We were able to inspect licence agreements issued by the housing association that manages the property. These are issued when people move in. Care Homes for Adults (18-65 years) Page 11 of 33 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Satisfactory care planning procedures are in place. There is satisfactory opportunity for people to participate in making choices and be involved in decision making. Staff enable people using the service to take an appropriate level of risk during their stay. These measures ensure the needs of people who use the service are met and they are given the opportunity to make choices during their stay. Evidence: Individual plans are prepared at the beginning of the rehabilitation programme for each person. There is evidence these are regularly reviewed with the person concerned and their key worker. From discussion and observation, people who use the service are as much as possible involved in making decisions about their lives, and how the service is run while they are staying there. Where restrictions are in place, these are recorded. Restrictions in place appear appropriate considering peoples needs. Care Homes for Adults (18-65 years) Page 12 of 33 Evidence: Suitable risk taking seems to take place to enable people using the service to live as independently as possible, and to minimise any risks people may present to others. These are reviewed as necessary. At the time of the inspection no monies were managed on behalf of people staying at the service. Care Homes for Adults (18-65 years) Page 13 of 33 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered persons ensure people staying at the service can live a lifestyle which meets their needs and wishes. Evidence: A twelve week rehabilitation programme is in operation. People using the service are resident at Chy Colum for the duration of the programme. The programme includes a range of group work, one to one sessions with therapists, self directed learning activity, required reading etc. All the people we spoke to were very positive about the rehabilitation programme provided. People have opportunity for recreational activities both as a group or individually according to their wishes. People have opportunity to visit friends and relatives and these people also visit the service. Routines in the home seem appropriate according to individual needs. People can Care Homes for Adults (18-65 years) Page 14 of 33 Evidence: spend their time in the part of the home where they wish. There was a relaxed and friendly atmosphere at the service throughout the time of the inspection. People staying at the service are involved in housework and cooking. A cook prepares the main meal at lunch time, and people using the service also are involved in food preparation in the evening and at week ends. Records also show people appear to have a varied and nutritious diet. People are involved in deciding the menu at resident meetings. Care Homes for Adults (18-65 years) Page 15 of 33 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Personal and health care needs of people living in the appear to be satisfactorily promoted and met. The management of medication needs some improvement. For example satisfactory stocks of prescribed medication need to be maintained and all staff must receive training regarding the handling of medication, if they are involved in this process. Evidence: We observed people using the service receiving suitable care and support from staff. Support was carried out in a professional, but relaxed and friendly manner. Documentation regarding how support is offered is satisfactory. All people using the service looked well cared for on the day of the inspection. People living in the service have suitable access to health care support during their stay (e.g. from GPs, dentists, district nurses, chiropodists, opticians etc.) We inspected the medication system. The medication policy seems satisfactory. Medication is stored appropriately in a medication cupboard. People using the service Care Homes for Adults (18-65 years) Page 16 of 33 Evidence: bring their own medication to the service when they come to stay. They are responsible for reordering medication, and have some involvement in administration. However, staff oversee the administration process, and sign for medication. The current recording system makes it quite difficult to audit that all prescribed medication is administered. We were able to ascertain that two people using the service did not appear to have a satisfactory supply of vitamin B tablets in stock. One person did not have a supply of prescribed paracetamol. Subsequently these prescribed medications did not appear to be being administered. The registered persons must ensure satisfactory stocks of prescribed medication are maintained for individual people using the service. However, if the registered persons want to ensure this matter remains the personal responsibility of the person concerned,but think it is necessary to maintain storage in the office, the matter needs to be risk assessed and documented. If staff remind individuals to reorder, when the person runs out of medication, this should be clearly documented in care notes. Some staff have received appropriate training regarding handling medication, although there was no evidence other staff involved in medication administration had received this. It is essential all staff involved in the administration of medication receive suitable training. Guidance regarding this is available on the CSCI website. We discussed the storage of medication which is deemed as controlled medication. Such medication is not routinely stored in the home. However, should stocks occasionally be held of this medication it is essential it is stored in a controlled drugs cabinet and recorded as such. Advice regarding this matter is available in the Royal Pharmaceutical Society guidelines. These are available free on their website. Care Homes for Adults (18-65 years) Page 17 of 33 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered persons have satisfactory complaints procedure, and this is publicised to the people using the service. The adult safeguarding procedure needs to be available for inspection. Staff need to be aware of its contents, and trained regarding safeguarding matters. These measures will help to ensure staff and people using the service know what to do if there are safeguarding allegations, and these allegations will be investigated appropriately. Evidence: A copy of the complaints procedure was inspected and this was satisfactory. Information regarding making complaints is contained in the service user guide. Staff on duty, and people who use the service, who we spoke to, were not aware of any complaints or concerns. The Commission for Social Care Inspection has not received any complaints during this inspection period. We would advise the registered provider to include information regarding access to the social services complaints procedure within their procedure, and /or within individual service user guides. People who are funded by local authorities have a right to use this procedure if they are funded by social services, and subsequently they should be made aware of this. We did not view a copy of the registered providers adult safeguarding procedure. The last inspection report stated this was satisfactory. However care staff and management Care Homes for Adults (18-65 years) Page 18 of 33 Evidence: could not find a copy of this, on the day of this inspection. The current procedure (if in existence) should be reviewed, staff need to be aware of it and it needs to be available for inspection. Staff need to attend adult safeguarding training (e.g. from Cornwall County Council) if they have not received this. We have no record of any safeguarding concerns at this service, and the people we spoke to, said they had no concerns regarding the attitudes of other staff or care practices in the home. Care Homes for Adults (18-65 years) Page 19 of 33 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Chy Colum provides a suitable facility for the people using the service. Evidence: The building was inspected. Up to eleven people can be accommodated at the service. The home is a spacious house.There is a kitchen, quiet room, an activity / computer room, a lounge and a dining room.There is suitable toilet and bathing facilities. It is advisable thermostatic valves are fitted to all bath and shower facilities to limit the risk of scalding if this has not been done. Some of the bedrooms are shared for two people. Decorations and furnishings are to a good standard. The home has a large pleasant garden which are accessible to the people living in the home. There is suitable car parking areas available. None of the bedrooms are accessible to wheelchair users, and it would be difficult for the service to accommodate somebody who was a wheelchair user or had significant difficulties with mobility. If finances allow, it would be a good idea for the housing association to develop a downstairs bedroom at the home. The home was clean, warm and light enough on the day of the inspection. The kitchen was clean. Laundry facilities are satisfactory. The outside of the building and the Care Homes for Adults (18-65 years) Page 20 of 33 Evidence: gardens were maintained to a satisfactory standard. Care Homes for Adults (18-65 years) Page 21 of 33 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels appear satisfactory to meet the needs of people currently accommodated at the home, although weekend and evening staffing levels need to be kept under review to meet the needs of those accommodated. Recruitment checks need improvement and all records must be maintained and made available for inspection. Improvement is required regarding staff training. These improvements will ensure there is appropriate evidence staff are appropriately recruited and vetted, and people who use the service are supported by suitably knowledgeable and skilled staff. Evidence: On the day of the inspection there was four therapeutic staff on duty during the day. These staff carry out care tasks but we were told they are also trained therapists. One residential support worker is on duty first thing in the morning and also in the evening. The support worker also sleeps in. An admin worker is also on duty during the day. A cook is employed to prepare and serve the main meal. The therapeutic staff do not work routinely at weekends or in the evenings. The registered provider should monitor staffing levels, particularly in the evenings and at weekends to ensure they are satisfactory-particularly if the needs of people referred and accommodated become higher in the future. It is important that satisfactory Care Homes for Adults (18-65 years) Page 22 of 33 Evidence: systems are in place (for example through the health and safety risk assessment process) to ensure any risks of violence are minimised to staff and people using the service; particularly as there is a lone worker on duty for significant periods of time. Personnel records were inspected for the staff on duty for the day of the inspection. These were only to an adequate standard. During inspections we check staff employed have received for example two references; a Protection of Vulnerable Adults First check (POVA First); a Criminal Records Bureau check (CRB); a completed application form and evidence of identification etc. It is of concern that a requirement was issued at the inspection on 26th March 2007 regarding personnel records and this has not been complied with. We did not see evidence that a POVA First check had been obtained for staff employed since the last inspection. The registered provider has told us that staff do not commence employment until a full CRB check has been returned. However one person appears to have commenced employment 17 days before the CRB check was dated, and there was no record of a POVA First check being obtained. We did not see evidence that a further two staff had a CRB check, although it was confirmed by the registered provider these checks had been completed. The cook was referred to as self employed. However, there was no evidence references, a POVA First check or a full CRB check had been obtained to ascertain the persons suitability and fitness for this contractual arrangement. Staff must not commence employment until the completion of a POVA First check or alternatively a full CRB check (at enhanced level) has been obtained. If a POVA First check is obtained, staff must not work unsupervised until a satisfactory CRB disclosure has been returned. Until this is received they must be supervised as outlined in the guidance issued by CSCI and the Criminal Records Bureau. There were no copies of references for one member of staff. The registered provider however confirmed these had been obtained and were being held at the organisations office. There is no record references were obtained for the self employed cook. It is essential that copies of all personnel information-required by the regulations is retained at the service and this information is available for inspection. We inspected training records for the same sample group of staff. By law staff require the following training: * Regular fire training in accordance with the requirements of the fire authority. *There must always be at least one first aider on duty (at appointed person level) *All staff must have manual handling training and should have regular updates of this (e.g. annually) *All staff must have basic training in infection control. * Care Homes for Adults (18-65 years) Page 23 of 33 Evidence: Staff who handle food receive food hygiene training. * All staff must have an induction and there needs to be a record of this. * Awareness training regarding the needs of people accommodated. The delivery of training is only adequate. A comprehensive staff induction checklist was inspected. There was a record this had been completed for some of the staff, but there was not a record for four of the eight records we inspected. This included the member of staff who had slept in the night before the inspection. At the last inspection on 26th March 2007 we concluded there needed to be an improvement in the delivery of training required by law. There is unsatisfactory evidence this statutory requirement is being complied with for the staff employed. For example from an assessment of the records of staff on duty we conclude: (1) Fire Training- there is a record that all staff and residents received training on 12/2/09 and one person received this training on 25/11/08. However there is no clear break down to help us to assess specific staff employed have all received the appropriate training. (2) First Aid- Suitable first aiders were on duty during the day of the inspection. However the person who slept in at the home the night before the inspection had no record of receiving this training, and the certificate of the person who was due to sleep in the night of the inspection had expired. (3)Some staff need to receive infection control training. There was no record staff had received this training although the organisations policy states staff should receive it. This training could be delivered via video/DVD based training. (4)Manual handling- No people accommodated appear to need assistance with manual handling. However, staff need basic training regarding the manual handling of inanimate objects, as outlined in the manual handling regulations. This could be for example via video /DVD based training. (5) Food handling- staff said they do not handle food. If there is any food handling-staff need appropriate training for example via the Food Standards Agency Better Food, Better Business guidelines. There was no evidence the cooks employed have up to date food handling certificates, although standards of kitchen cleanliness appeared satisfactory. It is essential staff (as appropriate) receive suitable training. The environmental health department can provide guidance regarding this matter. The previous requirement is therefore renotified. There appeared satisfactory evidence staff employed have received training regarding substance misuse issues and counselling. However, there is only evidence that one person has obtained a National Vocational Qualification in care. 50 of staff in individual care services should have a National Vocational Qualification in care. It is important that particularly the residential support workers have opportunity to obtain Care Homes for Adults (18-65 years) Page 24 of 33 Evidence: at least an NVQ 2 in care. If possible this should be tailored to the needs of the people accommodated in the home. We are concerned about the lack of compliance regarding staff recruitment checks and staff training. This is particularly of concern as we are now notifying the registered provider on a second occasion regarding these matters. Failure to comply with the regulations in these areas could put staff and people who use the service at considerable risk. We will check compliance regarding these matters after the statutory requirement deadlines have expired. Failure to comply with these requirements could ultimately result in enforcement action, and have a negative impact on the homes star rating. Care Homes for Adults (18-65 years) Page 25 of 33 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager and the staff team provide a good service to people who stay at Chy Colum. Quality assurance procedures appear generally satisfactory, although more focus is required to ensure recruitment checks and staff training are improved. Health and safety procedures and checks are generally to a satisfactory standard. However we have made a requirement in the staffing section regarding the delivery of health and safety related training. Suitable action must be taken particularly as this matter has now been notified twice. Evidence: The registered provider is Addaction, a registered charity supporting people with drugs and alcohol problems. The registered manager is Roland Bence who has managed the home for several years. Mr Bence was on annual leave when we completed this inspection, but the team leader, administrator and Assistant Director of Operations were present at the inspection. The registered provider generally has a satisfactory approach to quality assurance. For Care Homes for Adults (18-65 years) Page 26 of 33 Evidence: example satisfaction questionnaires are completed by people using the service and there are staff and resident meetings. We are however concerned that management systems have not picked up lack of compliance with our previous requirements regarding staff recruitment checks and staff training, and there has not been a satisfactory programme to address these shortfalls. The registered manager has supplied the commission with their Annual Quality Assurance Assessment (AQAA) (an annual dataset, and self assessment required by CSCI). This was completed to a satisfactory standard. Any notifications, required by the commission (e.g. regarding untoward incidents) appear to have been received by us. Addaction has an up to date and comprehensive set of policies and procedures. However we could not locate the adult safeguarding policy and the staff on duty were not aware whether such a policy is in existence. It is essential an up to date set of policies (particularly those required by regulation) are kept in the home, accessible to staff, and staff are aware of the existence of policies they need to have a knowledge of. The registered provider has a health and safety policy. There is a fire risk assessment. Testing of fire extinguishers and the fire system appear to have been completed appropriately by external contractors. Internal checks on the fire system appear to have been completed appropriately by staff (e.g.emergency call points and emergency lighting). Health and safety risk assessments have been completed. As stated earlier in the report, it is strongly advisable that the temperature of hot water is controlled via thermostat to reduce the risk of scalding. The health and safety risk assessments completed are dated October 2005 and February 2006, and therefore should be reviewed and further action taken as necessary. Suitable records regarding accidents and incidents are kept. Portable electrical appliances have been tested and appear satisfactory. The electrical hardwire circuit was tested and test results were satisfactory.Gas appliances have been serviced and deemed satisfactory. An up to date certificate of insurance was displayed. Care Homes for Adults (18-65 years) Page 27 of 33 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 34 19(5) The registered persons must 01/06/2007 ensure there is full and satisfactory information available regarding the recruitment of staff (e.g. as outlined in schedule 4.6. of the Care Homes Regulations 2002). This information must be available for inspection. The registered persons shall 01/10/2007 having regard to the size of the care home, the statement of purpose and the number and needs of service users ensure that the persons employed to work at the care home receive training appropriate to the work they are to perform. (For example training required by law and some of the training appropriate for this service is outlined within the body of the report.) 2 35 18(1) Care Homes for Adults (18-65 years) Page 28 of 33 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 20 13 The registered persons must 01/04/2009 ensure satisfactory stocks of prescribed medication are maintained for individual people using the service. If this is deemed the responsibility of the person concerned this must be clearly risk assessed and documented. This will ensure people using the service have a suitable supply of prescribed medication available to them. 2 20 13 Staff involved in the handling of medication must receive suitable training. This will help to give people who use the service more assurance that their medication is handled appropriately. 01/09/2009 3 23 13 Ensure there is an adult 01/09/2009 safeguarding procedure, it is available for inspection, staff Page 29 of 33 Care Homes for Adults (18-65 years) are trained regarding adult safeguarding issues and they are aware of the organisations adult safeguarding procedure. This will help to assure people who use the service that the correct safeguarding procedures are followed if there are any incidents of suspected abuse. 4 32 18 The registered provider must have a suitable approach to ensure care staff have access to obtaining a National Vocational Qualification in care. For example 50 of care staff should have at least an NVQ2 in care. This will help to ensure all staff have appropriate knowledge and skills to support people using the service. 5 34 19 The registered persons must 01/04/2009 ensure recruitment checks, required by the regulations, are completed. Suitable records of these must be maintained at the service, and made available for inspection. (Previous deadline of 01/06/07 not met Second Notification) This will help assure people using the service that they can be confident that 01/09/2009 Care Homes for Adults (18-65 years) Page 30 of 33 appropriate checks are completed to ascertain the fitness of the staff employed to support them. 6 35 18 Staff must receive suitable training required by law (for example as outlined in the body of the report). (Previous deadline of 01/10/07 not met Second Notification) This will help to ensure all staff have appropriate knowledge and skills (in accordance with the law.) to support people using the service. 7 39 24 Improve quality assurance systems (for example to ensure staff personnel records, and staff training are to a satisfactory standard and legal standards are maintained) This will help to ensure the quality of staff recruitment and training procedures meet regulatory requirements. 8 40 12 Update policies and procedures in the home, ensure staff are aware of these, and these documents are available for inspection. This will ensure there is organisational guidance, which meets regulatory requirements, to guide staff to carry out their work and 01/09/2009 01/09/2009 01/09/2009 Care Homes for Adults (18-65 years) Page 31 of 33 protect people using the service. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 22 Ensure there is reference to the Social Services Complaints procedure, in the homes complaints procedure, and /or service user guide, as people funded by local authorities have a right to use this if they have a concern or a complaint. Develop the facility to include a bedroom for a person with physical disabilities e.g. a wheel chair user. Fit thermostatic valves to bathing facilities Keep staffing levels under review; for example in relation to minimising any risks of violence to lone workers and other people using the service. 2 3 4 24 27 33 Care Homes for Adults (18-65 years) Page 32 of 33 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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