Inspection on 02/09/08 for Coachmans Drive (21)

This inspection was carried out on 2nd September 2008.

CSCI found this care home to be providing an Adequate 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coachmans Drive (21) 03/12/07

Coachmans Drive (21) 17/01/07

Coachmans Drive (21) 07/11/05

Coachmans Drive (21) 06/06/05

Coachmans Drive (21) 16/12/04

Coachmans Drive (21) 04/10/04

Similar services:

Clover House

Parkside

Park Lodge

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Park House

Extracts from inspection reports are licensed from CQC, this page was updated on 18/02/2010.

CARE HOME ADULTS 18-65 Coachmans Drive (21) 21 Coachmans Drive Croxteth Park Liverpool Merseyside L12 0NX Lead Inspector Daniel Hamilton Key Unannounced Inspection 2nd September 2008 09:00 Coachmans Drive (21) DS0000025240.V367763.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 Coachmans Drive (21) DS0000025240.V367763.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. Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coachmans Drive (21) Address 21 Coachmans Drive Croxteth Park Liverpool Merseyside L12 0NX 0151 220 9729 9999 No email www.c-i-c.co.uk. Community Integrated Care 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) Manager post vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD The maximum number of service users who can be accommodated is: 3 Date of last inspection 3rd December 2007 Brief Description of the Service: 21 Coachmans Drive is an accessible three bed-roomed bungalow that is situated in the Croxteth Park area of Liverpool. At present there are only two people living in the home. The service is provided by Community Integrated Care and is registered to provide personal care and support to three adults with a learning disability. There is one acting manager and a team of five staff that support the people who live in the home. The property has a large lounge that contains a dining area, a bathroom with bathing aids, kitchen and an office. There is a private, enclosed garden to the rear of the home and an open plan front garden and driveway. The home has a mini bus and there is also a local bus service within walking distance. The Care Home Fees are £1,529.87 per week. Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection took place over one day and lasted approximately 8 hours. Two people were being accommodated in the home at the time of the visit. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The Service Manager, Acting Manager and two support workers were spoken with during the visit. Likewise, the two people living in the home were encouraged to participate in the inspection process using their preferred methods of communication. All the key standards were assessed and progress/ action taken in response to the previous requirements and recommendations from the last key inspection in December 2007 was reviewed. What the service does well: 21, Coachmans Drive presented as a warm and caring environment. Staff were observed to be attentive to the support needs of the service users during the inspection and provided care and support in a respectful and dignified manner. The people living in the home at the time of the visit appeared relaxed and comfortable in their home environment and were observed to communicate and engage with the staff team in a positive and friendly manner. One of the service users reported; “I like living here. I am looked after well” and “The staff are great.” The people using the service were encouraged to participate in a range of activities and to maintain relationships with family members. The staff team continued to support the people living in the home to take responsible risks as part of an independent lifestyle and meals, activities and routines were flexible and varied to enable service users to exercise choice and control over their lives. Systems had been developed to respond to complaints and to ensure an appropriate response to suspicion or evidence of abuse. Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Since the last visit, the Acting Manager had developed a new Statement of Purpose and Service User Guide in a standard format. Some information required under the Care Home Regulations 2001 had not been included in both the documents. This issue should be addressed to ensure prospective and current service users have access to all the necessary information they require and the document should be developed in a format that is more suitable for the needs of people with learning disabilities. A new service user had moved into the home since the last visit. A preadmission assessments of need had been undertaken by Community Integrated Care staff however the assessment was very brief and did not include information on equality and diversity issues or the communication, mental health and / or medication needs of the service user. These issues should be addressed, to ensure an holistic assessment is completed. Furthermore, care plans should be developed as a matter of priority for new service users and / or updated to identify each person’s needs, the support required and individual goals. This will enable the service to demonstrate that it is person centred and provide staff with the necessary information to meet the needs of the people using the service. In order to ensure best practice, assessments of competency should be undertaken for all staff responsible for the administration of medication. This will help the service to monitor the training needs and competency of staff. Furthermore, action should be taken to ensure handwritten medication administration records are checked and witnessed by another suitably trained Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 7 staff member, to confirm the prescribed instructions are consistent with the details on the prescription. A record of the balance brought forward for medication and the date received, quantity, and details of the person receiving medication into the home should also be recorded on Medication Administration Records, to provide a clear audit trail. Some minor maintenance issues were identified during the visit. For example, none of the ceiling lights in the lounge / dining room were working and the hallway and some doorframes were in need of painting. Furthermore, the majority of rooms viewed required redecorating following the installation of a new central heating system and the kitchen units remained in need of modernisation. The paint in the laundry room also required attention as it was peeling off as previously noted. Action should be taken to address the maintenance issues, to ensure the environment remains homely and comfortable for the people using the service. Despite a requirement at the last inspection, some staff training and development records viewed were not up-to-date. This issue must be addressed and the training needs of staff should be closely monitored to ensure all staff complete all the necessary induction, safe working practice, core and specialised training that is relevant to their roles. At the time of the inspection the service did not have a manager who was registered with the Commission for Social Care Inspection. The Acting Manager should submit a completed application form for the position of Registered Manager to the Commission as a matter of priority, to ensure the best interests of the people using the service. The quality assurance system should also be further developed and the use of external advocates explored, to ensure the ongoing development of the service. 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. Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information on the service and the needs of prospective service users is in need of ongoing development, to ensure the service is able to meet the diverse needs of people who are considering moving into the home. EVIDENCE: Since the last visit a new Acting Manager had taken over responsibility for the management of the service and produced a new Statement of Purpose and Service User Guide in a standard format. The Acting Manager was advised to develop the documents in a suitable for the needs of people with a learning disability and to documents were updated to include all the information required Home Regulations 2001. Advice was given on how the layout of could be further improved. format more ensure the under the Care the document The Acting Manager reported that one person had moved into the home since the last visit for a period of short-term care. The other service user had lived in the home for over eighteen years. Previous inspection records detailed that the organisation had procedures in place in relation to undertaking assessments and the Annual Quality Assurance Assessment detailed that policies were in place for referral and admission. Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 10 The personal file of the new service user was viewed during the visit. Records showed that a member of staff had undertaken a basic assessment of need using a corporate assessment document. Advice was given to the management team on how the assessment document and recording could be further improved, as information on equality and diversity issues; communication; mental health needs and medication had not been recorded. Copies of assessments completed by a social worker and another care provider had been obtained for reference and these provided additional information for staff to reference. The Acting Manager reported that the Support and Tenancy Agreement for the new service user was not available in the home, as it had not been transferred from Head office. Copies of contracts were available on file for the other service user as previously noted. Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning records remain in need of development or review, to ensure the needs / goals of the people using the service are identified and planned for to promote independence, wellbeing and choice. EVIDENCE: The files of the two people living in the home were checked during the visit. Only one file viewed contained a care plan, as one of the residents had recently moved into the home. The acting manager reported that she would arrange for a care plan to be completed as a matter of priority. The other file viewed contained a range of care planning documentation as noted at the last visit. The documentation included a Care Plan, Support Guides and an Essential Lifestyle Plan. Records viewed had been kept under review however personal goals and objectives had not been included in the Essential Lifestyle Plan as previously noted. The management team and the carer on duty demonstrated a satisfactory awareness of the needs, routines and preferences of the people living in the Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 12 home, despite the absence of a care plan for one of the service users. Staff were observed to receive specialised training from a district nurse during the visit, to ensure they understood how to meet the health care needs of one of the service users. Both of the people using the service were present during the inspection and appeared relaxed in their home environment. One of the service users reported; “I like living here. I am looked after well.” Likewise, the other service user was seen to engage in a positive way with the staff team by smiling, touching and / or making responsive sounds. The staff team continued to support the people living in the home to take responsible risks as part of their daily lives. Risk assessments had been completed for only one of the people living in the home and these had been kept under review. Advice was given to the Acting Manager on how to further develop the risk assessment for the use of bedside rails, as the assessment had not been updated as recommended at the last visit. Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Meals, activities and routines were flexible and varied to enable service users to follow their preferred lifestyle. EVIDENCE: The people living at 21 Coachman’s Drive did not attend any employment or educational facility. The acting manager reported that the staff team continued to encourage the people using the service to utilise community facilities and to participate in all aspects of their home life where possible. Since the last visit one of the people living in the home had been supported to visit Blackpool for a five day holiday. Both of the people using the service maintained contact with family members. The acting manager reported that one of the people using the service had only recently re-established contact with a family member, with support from the staff team. There were no restrictions around visitors coming to the house and the people using the service were supported to form appropriate personal and family relationships. Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 14 Life in the home is based around what the people using the service want to do, unless there is a particular activity they need to attend. Service users can get up when they wish, spend time in the lounge or in the privacy of their own room as was seen on the day of inspection. The people using the service were assisted by staff to go shopping for household products, buy food and to prepare meals. Since the last visit, the acting manager had developed a menu planning system. A recommendation was made for the menu plan to be updated to also include the choices for breakfast and lunch-time meals, as only the option for each tea-time meal had been recorded. Systems were in place to ensure appropriate support was given by staff for people who required support with eating and drinking. Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of medication records remains in need of attention, to safeguard the healthcare needs of the people using the service. EVIDENCE: Only one of the people living at 21 Coachman’s Drive required assistance with all aspects of personal care and support. The Registered Provider (Community Integrated Care) had developed a range of care plan documentation for staff to record information on the support needs of the people using the service. At the time of the inspection only one file viewed contained a care plan as one of the service users had recently moved into the home. Staff spoken with during the visit were able to demonstrate knowledge and understanding of the personal needs and support requirements of the people living in the home. Furthermore, staff were observed to treat the people using the service with respect and dignity during the inspection process. Examination of medical records revealed that only one of the people living in the home had a Health Action Plan and health care records. Records detailed that a service user had been supported to attend appointments with a general practitioner, dentist, chiropodist and optician. Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 16 The Annual Quality Assurance Assessment for the service detailed that staff had access to a policy on the Control, Storage, Disposal, Recording and Administration of Medicines. A copy of a corporate Medication policy and local procedures were in place on the day of the inspection and guidance issued by the Royal Pharmaceutical Society of Great Britain had been obtained for reference. The acting manager was advised to include copies of the medication procedures in the medication files, to enable staff to reference the documents more easily. Medication was dispensed by a local pharmacist and administered by staff who had completed medication training. At the time of the visit, written assessments of competency had not been undertaken for staff responsible for handling medication however work books had been developed for staff to complete as part of their medication training. The Acting Manager reported that none of the people using the service administered their own medication. Medication consent forms had not been completed by the people using the service (where practicable) and / or their representatives and advice was given on how this should be developed. Medication was stored in individual medication cabinets that were fitted in each service user’s bedroom. Examination of Medication Administration Records (MAR) highlighted the following issues. Firstly, handwritten MAR had not been countersigned by another suitably trained member of staff, to confirm the prescribed instructions were correct and as detailed on the prescription. Secondly, although a medication count book had been established, details of the balance brought forward, date received, quantity and initials of staff had not been recorded on the MAR to provide a clear audit trail. These issues should be addressed. There were no controlled drugs in the home on the day of the visit. Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although some procedures remain in need of review, systems had been developed to listen and respond to complaints and to safeguard and protect vulnerable people from abuse. EVIDENCE: The Registered Provider (Community Integrated Care) had developed a corporate Complaints procedure however this had not been updated to include details of how to contact the Commission for Social Care Inspection as previously recommended. Previous inspection records confirm that the Complaints procedure had also been developed in an accessible format for people using the service to reference. Since the last visit, the acting manager had revised the Statement of Purpose and Service User guide. The Statement of Purpose did not include details of the Complaints Procedure and the contact details for the Commission for Social Care Inspection were incorrect in the Service User Guide. The management team agreed to update the documents to include the outstanding information. The Annual Quality Assurance Assessment for the service detailed that no complaints had been received since the last visit and this was verified by checking the complaints log record for the service. The Commission had also received no complaints about the home since the last inspection. Previous inspection records confirm that Registered Provider (Community Integrated Care) had developed an adult protection procedure and a whistleblowing policy. A copy of the Liverpool City Council Inter Agency Adult Protection Procedures was available in the home for staff to reference. Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 18 Training records showed that five of the six staff employed to work at 21 Coachman’s Drive had completed training in the Protection of Vulnerable Adults and staff spoken with demonstrated a good awareness of how to recognise and respond to suspicion or evidence of abuse. Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although the property is in need of some minor maintenance and redecoration, it is generally pleasant, clean and homely. This provides the people using the service with a safe, clean and comfortable environment. EVIDENCE: 21, Coachman’s Drive is a bungalow situated in the Croxteth Park area of Liverpool. It is in keeping with other properties in the area and there are no outward signs that it is a care home. It is currently registered to provide accommodation for 3 service users but the smallest bedroom has been converted to an office. The accommodation included a spacious lounge and dining area (which provided suitable access for people who use a wheelchair) and two bedrooms, a domestic style kitchen, bathroom and a staff office. There were spacious gardens to the rear of the building that were well maintained and accessible to wheelchair users. ‘Annual Scheme Monitoring visits’ were undertaken by Regenda (the Landlord) to monitor the condition of the building and a maintenance person was Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 20 employed by Community Integrated Care (The Registered Provider) to undertake minor maintenance tasks. The acting manager confirmed that the property had continued to receive investment since the last visit and reported that a new microwave, crockery and curtains and blinds had been purchased. At the time of the visit, the property was in need of some minor maintenance. For example, none of the ceiling lights in the lounge / dining room were working and the hallway and some doorframes were in need of painting. Furthermore, the majority of rooms viewed required redecorating following the installation of a new central heating system and the kitchen units remained in need of modernisation. The paint in the laundry room also required attention as it was peeling off as previously noted. The Annual Quality Assurance Assessment for the service detailed that policies and procedures had been developed for ‘communicable diseases and infection control’ and areas viewed during the visit appeared clean and hygienic. Records showed that all the staff team had completed training on the prevention and management of infection control. Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff training and development records and systems remain in need of ongoing attention, to demonstrate that the people using the service are supported by trained and competent staff. EVIDENCE: 21 Coachman’s Drive had an Acting Manager and a team of four permanent support workers and one regular bank staff. Two staff were on duty each day from 7.30 am to 8.00 pm and one waking night staff was on duty from 7.30 pm until 8.00 am. At the time of the visit the service had vacancies for three full-time staff and one part-time staff. The posts had not been recruited to as the existing staff had picked up extra shifts as and when required. The management team confirmed that the staffing levels and number of hours worked by staff continued to be closely monitored, to ensure the people using the service had access to sufficient numbers of staff and continuity of care at all times. The Annual Quality Assurance Assessment for the service detailed that the Registered Provider (Community Integrated Care) had a policy on recruitment and employment including redundancy. The Acting Manager reported that she Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 22 was the only new employee who had commenced employment in the home since the last inspection. The personnel file of the Acting Manager was examined during the inspection and found to contain the necessary records required under the Care Home Regulations 2001. The file of another staff member was also checked as only one reference was available for the employee at the previous inspection. No progress had been made in obtaining a second reference. This matter should be addressed. The Annual Quality Assurance Assessment for the service detailed that five of the staff had completed a National Vocational Qualification at level 2 or above in Care and that one bank staff was working towards the award. Upon reviewing the progress with National Vocational Qualifications with the management team it became clear that only one of the five staff had documentary evidence to confirm they had completed a National Vocational Qualification in Care at level 2 or above and that two staff were working towards the award. Once the two staff have completed the award and received their certificates, three staff (60 of the current team – excluding vacancies) will be qualified to NVQ level 2 or equivalent. Community Integrated Care had a training department, which delivered certain core training. The organisation had also developed a ‘CIC academy e-learning system’ which covered induction training; core skills part 1, 2 and 3; Safety at Work; Food Hygiene; Person Centred Learning; First Aid; Moving and Handling and Communicating Effectively. Practical training was also provided for Moving and Handling, First Aid and Basic Food Hygiene. A training plan was not in place for the staff at the time of the visit. Records confirmed that a training and development programme was sent to the service every six months, which listed a range of training for staff to access. Some training records viewed were not up-to-date and highlighted gaps and / or the need for refresher training in some key topics as previously identified. The Acting Manager reported that she had e-mailed the training department for Community Integrated Care to nominate staff for outstanding training and to request copies of certification (where necessary). A copy of an e-mail was available to confirm the training certificates / courses had been requested. Staff spoken with during the visit confirmed they had access to training opportunities and had started to receive formal supervision from their line manager. Coachmans Drive (21) DS0000025240.V367763.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 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration of service and assessment information, staff training and development and quality assurance is in need of ongoing development and review in order to demonstrate that the service is run in the best interests of the people using the service. EVIDENCE: At the time of the visit the home did not have a manager who was registered with the Commission for Social Care Inspection. Since the last visit, Nicola Trousdale had been appointed as the Acting Manager of the service by the Registered Provider (Community Integrated Care). The Acting Manager reported that she had completed an application form to become the Registered Manager of the service and confirmed that the application pack would be returned to the Commission for Social Care inspection as a matter of priority. Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 24 The Acting Manager also reported that she was due to commence the level 4 National Vocational Qualification (NVQ) – Registered Manager’s Award in the near future and advice was given regarding the need to also complete a level 4 NVQ in Health and / or Social Care. Examination of the training record for the Acting Manager revealed that the Manager had completed a ‘Managers Foundation course’ and other training relevant to her role. Gaps in Safe Working Practice training were noted as identified in the section entitled ‘staffing’. Feedback received from staff and the people using the service via surveys and / or discussion confirmed the acting manager was supportive and approachable. Prior to the inspection the Acting Manager completed an Annual Quality Assurance Assessment for the service. The information was informative but very similar in content to another regulated service. Advice was given to the management team on how the content of the document could be further developed. Records were available to confirm the Service Manager had continued to undertake Regulation 26 visits to the home on behalf of the Registered Provider. This involved carrying out an audit of all aspects of the service users health and welfare, the environment, complaints and staffing levels. A monthly ‘core standards review’ process was undertaken during this visit as part of the quality assurance process and quality audits were also completed on a sixmonthly basis. The Acting Manager reported that an annual quality assurance ‘service user survey’ had been undertaken since the last visit. At the time the survey was undertaken only one person was living in the home. Examination of the survey form revealed the questionnaire had been completed by staff employed by Community Integrated Care and was not dated. Advice was given on how the Quality Assurance process could be further improved by seeking the involvement of independent advocates and / or relatives (where practicable). Minutes of staff meetings were available however records identified that there had been no recent team meetings. Information received via the Annual Quality Assurance Assessment (dataset) for the service confirmed policies and procedures had been developed on Health and Safety. Likewise, the dataset confirmed that equipment in the home had been serviced and / or tested periodically. Examination of the fire records for the home confirmed the fire alarm system had been tested each week and the emergency lighting on a monthly basis. A sample of service certificates were also viewed for: the fire alarm system; fire extinguishers and blankets; portable appliance testing; gas safety certificate, Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 25 electrical wiring and hoisting equipment and all were found to be up-to-date and in order. An up-to-date fire risk assessment was also in place. The Acting Manager was advised to monitor and record the temperature of hot water outlets accessed by the people using the service, to confirm the temperature is appropriately regulated. Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 26 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 2 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 3 X Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 27 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 YA35 Regulation 17 (2) Schedule 4 Requirement Each member of staff must have an up-to-date record of training completed including induction training, to provide evidence that the people using the service are supported by an appropriately trained team. [Previous timescale of 3/02/08 not met]. Timescale for action 01/11/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The Statement of Purpose / Service User Guide should be updated to include all the information required under the Care Home Regulations 2001 and produced in a format that is more suitable for the needs of people with learning disabilities. Pre-admission assessments of need undertaken by Community Integrated Care staff should be detailed and include information on: equality and diversity issues; communication; mental health needs and medication, to ensure an holistic assessment is completed. DS0000025240.V367763.R01.S.doc Version 5.2 Page 28 2 YA2 Coachmans Drive (21) 3. YA6 4. 5. 6. YA17 YA19 YA20 7. YA20 8. YA20 9. YA22 10 11. 12 YA24 YA32 YA35 13 YA37 Care plans should be developed as a matter of priority for new service users and / or updated to identify each person’s needs, the support required and individual goals. This will enable the service to demonstrate that it is person centred and provide staff with the necessary information to meet the needs of the people using the service. The menu plans should be updated to detail the choices for breakfast and lunch-time meals, to clarify the choice of meals on offer for the people using the service. A health action plan should be developed for the new service user as a matter of priority, to promote and safeguard the healthcare needs of the service user. Action should be taken to ensure handwritten Medication Administration Records are checked and witnessed by another suitably trained staff member, to confirm the prescribed instructions are consistent with the details on the prescription. The will help to safeguard the health and welfare of the people using the service. Assessments of Competency should be undertaken on all staff responsible for the administration of medication. This will help the service to monitor the training needs and competency of staff and to ensure best practice. A record of the balance brought forward for medication and the date received, quantity, and details of the person receiving medication into the home should be recorded on Medication Administration Records, to provide a clear audit trail. The contact details of the Commission for Social Care Inspection should be included in the Organisation’s Complaints procedure and the Statement of Purpose for the service, so that people are aware of how to contact the Commission. Action should be taken to address the maintenance issues identified in this report, to ensure the environment remains homely and comfortable. 50 of the staff team should hold a National Vocational Qualification at level 2 or equivalent to ensure compliance with National Training Targets. The training needs of staff should be closely monitored and recorded, to ensure all staff complete the necessary induction, safe working practice, core and specialised training that is relevant to their roles. This will help to ensure staff are trained and competent to undertake their roles effectively. The Acting Manager should submit a completed application form for the position of Registered Manager to the Commission for Social Care Inspection as a matter of priority, to ensure the best interests of the people using DS0000025240.V367763.R01.S.doc Version 5.2 Page 29 Coachmans Drive (21) 14 YA39 the service. The quality assurance system should be further developed and the use of external advocates explored, to ensure the ongoing development of the service. Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Coachmans Drive (21) DS0000025240.V367763.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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