Inspection on 12/08/08 for Coachmans Drive (51)

This inspection was carried out on 12th August 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coachmans Drive (51) 19/11/07

Coachmans Drive (51) 24/10/06

Coachmans Drive (51) 04/02/06

Coachmans Drive (51) 26/11/05

Coachmans Drive (51) 18/02/05

Coachmans Drive (51) 04/08/04

Coachmans Drive (51) 02/03/04

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 08/11/2008.

CARE HOME ADULTS 18-65 Coachmans Drive (51) 51 Coachmans Drive West Derby Liverpool Merseyside L12 0HX Lead Inspector Daniel Hamilton Key Unannounced Inspection 12th August 2008 08:30 Coachmans Drive (51) DS0000025241.V365163.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 (51) DS0000025241.V365163.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 (51) DS0000025241.V365163.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coachmans Drive (51) Address 51 Coachmans Drive West Derby Liverpool Merseyside L12 0HX 0151 228 2295 0151 228 2295 croxteth.park@unitedresponse.org.uk None United Response 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 2 Category(ies) of Learning disability (2) registration, with number of places Coachmans Drive (51) DS0000025241.V365163.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th November 2007 Brief Description of the Service: 51 Coachmans Drive is a two bed-roomed bungalow that is situated in the Croxteth Park area of Liverpool. The service is provided by United Response and is registered to provide personal care and support to two adults with a learning disability. There is one acting manager and a team of staff that support the people who live in 51 and 53 Coachmans Drive. Both 51 and 53 Coachmans Drive are identical in layout and adjacent to each other. Each property has a large lounge, dining area, kitchen and a small spare room. The spare room in 51 Coachmans Drive is used as an office. Likewise, the spare room in 53 Coachmans Drive is used as a staff ‘sleep-in’ area. There are gardens to each of the properties. The property is decorated and furnished to a high standard and provides a homely environment that is domestic in character. Care Home Fees range from £369.00 per week. Coachmans Drive (51) DS0000025241.V365163.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 9.5 hours. Two people were living 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 Area Secretary and four support workers were spoken with during the visit. Likewise, the two people who were living in the home were encouraged to participate in the inspection process using their preferred methods of communication. Survey forms were also distributed to each of the people using the service and a number of staff prior to the inspection, in order to obtain additional views and feedback about the service provided. All the key standards were assessed and progress/action taken in response to the previous requirement and recommendations from the last key inspection in November 2007 was reviewed. What the service does well: 51 Coachman’s Drive is a small home, which works on the principles of ordinary community living. The home offers a small and homely environment, which presents as being welcoming and friendly. The service supported the people living in the home to remain as independent as possible and to take responsible risks as part of their lifestyle. The service users were actively encouraged to participate in a range of community-based activities and to maintain relationships with their families and friends. Staff were observed to provide care and support to the people using the service in a dignified and respectful manner and were seen to interact and engage with the service users throughout the day. The people using the service were observed to be relaxed and comfortable in their home environment and were seen to respond positively to staff interaction by smiling, touching, gestures and / or responsive sounds. Staff spoken with during the visit were able to communicate effectively with the people using the service and demonstrated a sound awareness of the principles of good care practice and equality and diversity issues. Coachmans Drive (51) DS0000025241.V365163.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: A Service User Guide had been developed for Coachmans Drive in a standard format. As previously recommended, arrangements should be made to produce the document in a format more suitable for the needs of people with a learning disability, to enable people to understand the information more easily. Copies of assessments and individual contracts / statements of terms and conditions were not available in the home for inspection as they were stored at head office. As previously recommended, copies should be available for inspection, to confirm the needs of service users are identified and reviewed and that people are aware of their rights and obligations. Some Care Planning records were missing, not up-to-date or in need of additional information as noted at the last visit. Furthermore, some medical profiles had not been kept up-to-date. Action must be taken to address these issues in order to verify that the changing needs and personal goals of the people using the service are monitored, reviewed and appropriately planned for. Examination of Medication Administration Records (MAR) revealed that staff had not always recorded the administration of prescribed medication on MAR. MAR must always be completed to verify that medication has been administered in accordance with the prescribed instructions. It is strongly recommended that competency assessments are undertaken periodically, to confirm staff fully understand all aspects of the organisation’s medication procedures. Coachmans Drive (51) DS0000025241.V365163.R01.S.doc Version 5.2 Page 7 Some parts of the home were in need of maintenance, cleaning and / or refurbishment. Action should be taken to address the issues identified during the visit in order to ensure that service users benefit from a homely and comfortable environment. The Annual Quality Assurance Assessment (AQAA) for the service detailed that seven of the thirteen staff had completed a National Vocational Qualification in Care at level 2 or above however documentary evidence could be found for only 5 staff. Documentary evidence of National Vocational Qualifications should be obtained and available for inspection, to confirm a minimum of 50 of staff have completed the award. Furthermore, all staff should complete or receive refresher training in Safe Working Practice topics (where necessary) to promote and safeguard health and safety. The Registered Provider (United Response) had developed an auditing / quality assurance manual entitled “Getting It Right”, which was used throughout the organisation. At the time of the visit no evidence was available to verify that the views of the people using the service and / or their representatives had been obtained. Evidence of consultation with the people using the service and / or their representatives should be available for inspection, to confirm their feedback / views are obtained as part of the quality assurance process. An electrical wiring certificate should also be obtained / available for inspection to confirm the electrical wiring installation is safe. 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 (51) DS0000025241.V365163.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 (51) DS0000025241.V365163.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. Policies and procedures are in place to ensure the needs of prospective service users are assessed prior to moving into the home. EVIDENCE: A ‘Guide for People we Support’ had been produced by the Registered Provider (United Response) in a standard format. No action had been taken to develop the information into a format more suitable for the needs of people with a learning disability, as recommended at the last visit. Furthermore, despite a recommendation at the last visit copies of contracts had not been obtained from the Registered Provider’s head office in Putney, to provide evidence that the people using the service and / or their representatives were aware of their rights and obligations. The Annual Quality Assurance Assessment (AQAA) for the service and previous inspection records confirmed that United Response (Registered Provider) had developed policies and procedures in relation to referral and assessment. No new service users had moved into Coachmans Drive since the last visit and records showed that the two people living in the home had been in residence for a number of years. As identified in previous inspections, the original assessments for the two people living in the home had been archived and an Coachmans Drive (51) DS0000025241.V365163.R01.S.doc Version 5.2 Page 10 up-to-date assessment of need was not in place for each person living in the home. Coachmans Drive (51) DS0000025241.V365163.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. The management of care planning remains in need of ongoing development and review. This will help to confirm that the changing needs of the people using the service are recognised and planned for to promote independence, wellbeing and choice. EVIDENCE: The personal files of the two service users living in the home were viewed during the visit. Each file contained a range of documentation including Support and Essential Lifestyle Plans (ELP). One of the two support plans viewed had a number of sections that had not been completed and both documents had not been dated to confirm they had been kept under review. Furthermore, although there was evidence on files to confirm Essential Lifestyle review meetings had been carried out for both the people using the service during November 2007, only one ELP could be located and this was dated prior to the review. Other supporting documentation including; communication profiles, active support guidance, listen to me workbooks, medical profiles and / or Intimate and Personal Support records had been completed. The majority of documents Coachmans Drive (51) DS0000025241.V365163.R01.S.doc Version 5.2 Page 12 had been kept under review however some gaps were noted and this should be addressed. Staff were able to give examples of how they communicate with the people using the service and demonstrated a sound awareness of the principles of good care practice and equality and diversity issues. The opportunity for the service users to make decisions and their needs known relies to some extent on the staff team understanding and responding to their non-verbal communications. The people using the service were observed to be relaxed and comfortable in their home environment and were seen to respond positively to staff interaction by smiling, touching, gestures and / or responsive sounds. Discussion with staff confirmed the people living in the home were encouraged to take appropriate risks associated with the normal aspects of daily life and staff were available at all times to offer support. The people using the service were encouraged to actively participate in their local communities and a range of risk assessments had been completed for each service user in order to identify and control environmental, health and safety and person-centred risks. It was noted that no action had been taken in updating the risk assessment for the use of bed rails as previously recommended. Coachmans Drive (51) DS0000025241.V365163.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Meals, activities and routines were flexible and varied to enable service users to follow their preferred lifestyle. EVIDENCE: The people living at 51 Coachmans Drive were supported to lead a fulfilling lifestyle by engaging in a range of person-centred leisure and recreational activities. Each person using the service had an activities programme as previously noted. Discussion with staff and examination of activity records confirmed the people using the service had continued to receive support to enable them to participate in various leisure, recreational and community based activities e.g. voluntary work, swimming, bowling, pictures, hairdressing and personal shopping. One of the service users was also a supporter of Everton Football Club and enjoyed attending home games at Goodison Park. Coachmans Drive (51) DS0000025241.V365163.R01.S.doc Version 5.2 Page 14 Since the last visit, both the people living in the home had also been supported to have an annual holiday. One person had visited Devon and stayed in a cottage and the other person had visited Wales and stayed in a log cabin. The area secretary reported that the people using the service continued to have regular contact with family and records of contact had been appropriately recorded. Personal files contained evidence that Essential Lifestyle Plan (ELP) review meetings had been organised periodically, to review each person’s personal goals and aspirations. Although Essential Lifestyle review meetings had been carried out for both the people using the service, it was noted that one Essential Lifestyle Plan could not be located and another had not been updated following a review meeting. Similar issues were noted at the last visit. Service users were assisted by staff to go shopping for household products, buy food and to prepare meals. Since the last visit, a four-week rolling menu plan had been developed in consultation with advocates i.e. family members and each service user had a diet book with a record of meals. At the time of the visit the service had a £120.00 weekly allowance for food (shared between the two houses). Staff provided varying levels of assistance to the people using the service with eating and drinking and the area secretary confirmed that specialist advice would be sought from the dietician and / or speech and language therapist, subject to individual need. Coachmans Drive (51) DS0000025241.V365163.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. Some personal and health care records remain in need of review to safeguard the health and welfare of the people using the service. EVIDENCE: The two people living at 51 Coachmans Drive required assistance with all aspects of personal care and support. The Registered Provider (United Response) had developed a range of documentation including Support Plans, Essential Lifestyle Plans and / or information on Intimate and Personal Support to provide information on the support needs of the people using the service. Although some of this important information was either incomplete, missing or in need of review, staff spoken with were able to demonstrate an awareness of the needs, preferences and preferred routines of the people using the service. Furthermore, staff were observed to offer support to service users in a personcentred and dignified manner. Each person using the service had a ‘Medical Profile’. One of the two records viewed had not been fully completed and some sections were incomplete. Coachmans Drive (51) DS0000025241.V365163.R01.S.doc Version 5.2 Page 16 Summary records of health care appointments detailed that the people using the service had accessed; speech and language therapists; dentists; opticians; general practitioners; hospital staff; chiropodists and / or dieticians subject to individual need. 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 the corporate medication policy was stored in the “Getting it Right” quality manual and brief local procedures had also been developed for staff to reference. None of the people using the service self-administered medication at the time of the visit. Medication was dispensed by a local pharmacist and administered by staff who had completed in-house training. An identification system had been established to help minimise administration errors and record of staff authorised to administer medication, together with sample signatures was available for reference. No assessments of competency had been completed as previously recommended. Medication Administration Records (MAR) viewed had generally been correctly completed to account for medication received and administered. It was noted that staff had not recorded the administration of a prescribed cream on a MAR chart for one service user and this matter must be addressed. Records of medication received and balance checks were recorded on a separate record. Staff were advised to record the balance brought forward on to MAR sheets. Since the last visit handwritten entries on MAR charts had been checked and signed by another suitably trained member of staff to verify that the recorded prescribed instructions were consistent with the prescription details. Competency assessments had not been undertaken for staff responsible for administering medication, as previously recommended. Coachmans Drive (51) DS0000025241.V365163.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. Systems had been developed to listen and respond to complaints and to safeguard and protect service users from abuse. EVIDENCE: The Registered Provider (United Response) had developed a corporate complaints procedure, which explained what people should do if they had a complaint. The procedure had also been developed in a pictorial format that was suitable for the needs of people with a learning disability. Previous inspection records confirmed that service users and / or their relatives had received a copy of the complaints procedure. One of the procedures in a service user’s file remained in need of review as it did not include the name or contact details of the Commission for Social Care Inspection. Similar issues were also noted at the last inspection. Previous inspection records confirmed that service users and / or their relatives had received a copy of the complaints procedure. The Annual Quality Assurance Assessment (AQAA) for the Service detailed that one complaint had been received since the last service and this was verified by examining the complaint log for the service. Examination of records and discussion with staff revealed that the complaint had not been received by the home. The complaint had been made by the Registered Provider on behalf of the people using the service and concerned the treatment of the service users whilst trying to access a café in the community. Details of the incident were referred to the Equality and Human Coachmans Drive (51) DS0000025241.V365163.R01.S.doc Version 5.2 Page 18 Rights Commission in a proposed disability discrimination claim. The matter has since been settled out of court in favour of the service users. The people using the service were observed to be relaxed and comfortable in their home environment. Staff spoken with demonstrated a good understanding of the complex communication needs of the people they cared for and information on how to communicate with each service user was available within individual files viewed. The Registered Provider (United Response) had developed an Adult Protection and Prevention of Abuse and a Whistle-blowing policy and a copy of the Liverpool Inter Agency Vulnerable Adult Protection Procedures was available for staff to reference. Staff spoken with during the visit confirmed they had completed ‘Abuse’ training and demonstrated a good awareness of the different types of abuse and reporting procedures. The training matrix for the service detailed that 12 of the fourteen staff team had completed abuse training. Previous inspection records detail that the Registered Provider had also developed a policy in relation to management of service users money and financial affairs. Service users monies held were not checked during the inspection. Coachmans Drive (51) DS0000025241.V365163.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some parts of the home are in need of repair, maintenance and / or refurbishment in order to provide the people living in the home with a safe, clean and / or comfortable environment. EVIDENCE: 51 Coachmans Drive is a two-bedroom bungalow that is adjacent to its sister home, which is an identical property. The home had a spacious lounge and dining area. Laundry facilities were domestic in character and situated in the kitchen where service users could use them. The kitchen had a worktop available, which was at a level that enabled the people using the service to assist from their wheelchairs. The home had one adapted bathroom for use by the people living in the home and staff. The bathroom was equipped with a raised bath with tracking system and a shower and a changing table with overhead hoist. Records confirmed that the hoisting equipment was serviced at appropriate intervals. Coachmans Drive (51) DS0000025241.V365163.R01.S.doc Version 5.2 Page 20 The home did not have an alarm call system installed. Previous records detail that staff placed individual monitors in service users bedrooms to alert staff in the event of a service user(s) experiencing difficulties. Records were also available to confirm that a night support worker also undertakes regular recorded checks. Both service user had their own bedrooms which were pleasantly decorated, furnished and had been personalised with assistance from staff. Contractors were hired for the gardens and to maintain the home and environment as and when required. Jobs in need of attention and / or hazards were recorded in a health and safety maintenance file and records confirmed that weekly, monthly, quarterly, six monthly and annual health and safety checks were completed. On the day of the visit the home was generally clean and tidy however some parts of the home were in need of attention, maintenance and / or refurbishment. For example, the edging strips in the kitchen were damaged, the carpet in the lounge and hallway was stained / stretched, toilet was dirty and the varnish on some doors was scratched. One of the service user’s carpet was also stained. Since the last visit, some new bedroom furniture had been purchased for a service user. Coachmans Drive (51) DS0000025241.V365163.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service benefit from staff who are appropriately recruited and receive training to undertake their role effectively. EVIDENCE: 51 and 53 Coachmans Drive had been allocated a combined team of 12 permanent and two relief staff (including the registered manager) to provide direct care and support to the two people who lived in each property. At the time of the visit there was a vacancy for one part-time employee. The area secretary confirmed that the Registered Provider (United response) were in the process of recruiting to the post. The staff team consisted of: one Registered Manager; three senior waking night staff; three senior day support staff; six senior residential support staff and two relief staff. Staffing levels during the day varied dependent upon the needs / routines of the people using the service. During the night, one staff member undertook sleep-in duties (based in 53 Coachmans Drive) and another undertook waking night duties covering both 51 and 53 Coachmans Drive. Coachmans Drive (51) DS0000025241.V365163.R01.S.doc Version 5.2 Page 22 The Annual Quality Assurance Assessment for the service detailed that the Registered Provider (United Response) had a policy on recruitment and employment including redundancy. Recruitment was coordinated by the Registered Provider’s Human Resources Department. The area secretary reported that no new staff had commenced employment at 51 and 53 Coachmans Drive since the last visit. Recruitment records pertaining to two existing staff were reviewed, as the files did not contain evidence to confirm that a Protection of Vulnerable Adult and / or Criminal Record Bureau check had been completed at the last visit. Examination of the files revealed that the Registered Provider had provided written confirmation to confirm the two staff had undertaken a Criminal Record Bureau check. The area secretary was advised to also record the date of issue for reference. The Annual Quality Assurance Assessment (AQAA) for the service detailed that 7 (49.99 ) of the 13 staff members (excluding the Registered Manager) had achieved a National Vocational Qualification (NVQ) level 3 in Promoting Independence or Direct Care. On the day of the visit, documentary evidence of National Vocational Qualifications could be located for only five (38.46 ) staff. The AQAA also detailed that one employee was working towards the award. The area secretary reported that the Registered Provider had developed a corporate induction package, which was based upon the ‘Skills for Care’ Common Induction Standards. Records of inductions were available on the two staff files viewed however one had not been fully completed by the employee and the outcome and method of learning sections had not been signed off by the Registered Manager. Staff files viewed did not contain a record of training completed as previously noted. The area secretary was able to provide a training matrix for the staff team and this detailed that the majority of the staff had completed safe working practice training e.g. First Aid, Food Hygiene, Health and Safety, People Moving People etc. The training matrix highlighted that some staff were in need of refresher training for some Safe Working Practice topics as previously noted and the area secretary confirmed that this training need would be addressed. Staff spoken with during the visit reported that they had completed a range of training during their employment with United Response. This included; Induction, Safe Working Practice, Medication, Equality and Diversity, Abuse and specialised training geared towards the needs of the people using the service. Coachmans Drive (51) DS0000025241.V365163.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of administration in the home remains in need of ongoing development and review, in order to safeguard the welfare of the people using the service. EVIDENCE: Since the last visit, Barbara Moore had registered with the Commission for Social Care Inspection as the manager of the service. The Registered Manager was not available on the day of the visit to assist with the inspection process and arrangements were made by the Service Manager for the Area Secretary to be present. Documentary evidence was available to confirm the Registered Manager had completed the level 4 National Vocational Qualification (NVQ) - Registered Manager’s Award and the Area Secretary reported that the manager had recently been nominated to undertake a level 4 NVQ in Care. Coachmans Drive (51) DS0000025241.V365163.R01.S.doc Version 5.2 Page 24 Examination of training certificates confirmed the manager had continued to update her training and knowledge since the last visit. For example, certificates for: ‘Disciplinary Investigations’; ‘Mental Capacity Act Awareness’, ‘Principles of Manual Handling’; ‘First Aid Awareness’; ‘Medication Awareness’ and ‘Food Hygiene Awareness’ were available for reference. Feedback received from staff via discussion and surveys confirmed the manager was supportive and approachable. For example, one person reported; “The manager is very supportive, we have regular supervision and she is always available if we need her in between.” The Annual Quality Assurance Assessment for Coachmans Drive confirmed that Quality Assurance and monitoring systems were in place for the service as noted at the last visit. The Registered Provider (United Response) had developed a comprehensive auditing / quality assurance manual entitled “Getting It Right” which was used throughout the organisation. At the time of the visit no evidence was available to verify that the views of the people using the service and / or their representatives had been consulted on the quality of the service. Monthly visits had been undertaken by the Service Manager on behalf of the Registered Provider, in addition to organisational audits. Minutes were also available to confirm staff meetings were coordinated each month. 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 records confirmed that equipment in the home had been serviced and / or tested periodically. Fire records were viewed for the property. Records confirmed that the fire alarm system had been tested on a weekly basis and that weekly, monthly, quarterly, six monthly and annual health and safety checks were completed. A sample of service / maintenance certificates was viewed during the inspection. Evidence was available to confirm the fire alarm system, fire extinguishers, thermostatic safety valves, central heating boiler, hoists, bock beds and portable appliances had been tested. No certificate was available to confirm the electrical wiring installation in the property was safe. Staff reported that they had access to a range of Safe Working practice training as part of their role however training records showed that some staff were in need of refresher training for some topics as noted at the last inspection. Coachmans Drive (51) DS0000025241.V365163.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 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 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 3 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 2 X Coachmans Drive (51) DS0000025241.V365163.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 YA6 Regulation 15 (2) Requirement Care plans must be kept up-todate and reflect the changing needs and personal goals of the people using the service. This will help new and existing staff to understand the support requirements of the people using the service [Previous timescale of 19/01/08 not met]. The administration of all prescribed medication, including creams, must be recorded on a medication administration record to verify that medication has been administered in accordance with the prescribed instructions. Timescale for action 12/09/08 2 YA20 13 (2) 12/09/08 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 Service User Guide should be produced in a format more suitable for the needs of people with a learning disability, to ensure the information is more accessible for DS0000025241.V365163.R01.S.doc Version 5.2 Page 27 Coachmans Drive (51) 2. 3. YA2 YA5 4. YA9 5. 6. 7. YA19 YA20 YA24 8. YA32 9. YA39 10. YA42 prospective service users. Assessments of need should kept under review to ensure the changing needs of the people using the service are identified and planned for. Copies of individual contracts / statements of terms and conditions should be available for inspection to confirm the people using the service and / or their advocates are aware of their rights and obligations. The Risk Assessments for the use of bedrails should be further developed in accordance with guidance issued by the Medical Devices Agency. This will ensure best practice and protect the health and safety of the people using the service. Medical Profiles must be kept up-to-date to provide evidence that the health care needs of the people using the service are promoted and maintained. Competency assessments should be undertaken periodically on staff designated with responsibility for administering medication, to ensure best practice. Action should be taken to address the maintenance and refurbishment issues identified during the visit. This will help to ensure that service users live in a homely, comfortable and safe environment. Documentary evidence of National Vocational Qualifications should be obtained and available for inspection, to confirm a minimum of 50 of staff have completed the award. Evidence of consultation with the people using the service and / or their representatives should be available for inspection, to confirm their feedback / views are obtained as part of the quality assurance process. An electrical wiring certificate should be obtained / available for inspection to confirm the electrical wiring installation is safe. Furthermore, all staff should receive complete / receive refresher training in Safe Working Practice topics (where necessary) to promote and safeguard health and safety. Coachmans Drive (51) DS0000025241.V365163.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Waterloo, Liverpool L22 OLG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Coachmans Drive (51) DS0000025241.V365163.R01.S.doc Version 5.2 Page 29 - 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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