Inspection on 19/11/07 for Coachmans Drive (51)

This inspection was carried out on 19th November 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coachmans Drive (51) 12/08/08

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 08/07/2008.

CARE HOME ADULTS 18-65 Coachmans Drive (51) 51 Coachmans Drive West Derby Liverpool Merseyside L12 0HX Lead Inspector Daniel Hamilton Key Unannounced Inspection 19th November 2007 09:30 Coachmans Drive (51) DS0000025241.V349521.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.V349521.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.V349521.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 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) None United Response Vacancy Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Coachmans Drive (51) DS0000025241.V349521.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th October 2006 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 £2050.00 per week. Coachmans Drive (51) DS0000025241.V349521.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted approximately 8 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 acting manager 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 family members/advocates of each of the people using the service, health care professionals and 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 October 2006 was reviewed. What the service does well: 51 Coachmans Drive presented as a warm and caring environment. The home was generally decorated to a good standard and the people using the service appeared relaxed and comfortable in their home environment. Service users were encouraged to participate in a range of activities and to maintain relationships with their families and friends. Feedback received from the relatives of the people using the service was positive. Comments included; “The care is very good”; “They do as much as we would expect them to” and “Our daughter’s special needs - personal to her only are always top priority.” Staff spoken with during the visit demonstrated a satisfactory awareness of the needs of the people they cared for, equality and diversity issues and the principles of good care practice. The service was focussed around the needs of the people using the service and staff were observed to treat the service users with respect and in a dignified manner. 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. A range of risk assessments had also been completed to identify and control potential risks. A programme of self review and service monitoring had been established which involved consultation with the representatives of the people using the service. Coachmans Drive (51) DS0000025241.V349521.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Some Care Planning records and associated documentation was incomplete and / or had not been updated following service reviews. This matter must be addressed to ensure the changing needs and personal goals of the people using the service are documented for new and existing staff to reference. Recruitment records did not provide evidence that staff had been employed following the receipt of a Protection of Vulnerable Adult and / or Criminal Record Bureau certificate. Likewise, one member of staff had commenced employment prior to the receipt of two satisfactory references. These issues must be addressed to confirm the welfare of the people living in the home is safeguarded. At the time of the visit the Service User Guide had not been produced in a format suitable for the needs of people with a learning disability. The document should be updated to ensure the information is more accessible for prospective service users. Copies of individual contracts / statements of terms and conditions were not available for inspection as they were stored at the Organisation’s head office. Copies should be available for inspection to confirm the people using the service and / or their representatives 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. Information on the outcome of health care appointments had not routinely been recorded. Medical Profiles must be kept up-to-date to provide evidence that the health care needs of the people using the service are appropriately maintained. Coachmans Drive (51) DS0000025241.V349521.R01.S.doc Version 5.2 Page 7 It is recommended that a record of the sample signatures of staff responsible for administering medication be established. Likewise, competency assessments should be undertaken periodically and handwritten entries on Medication Administration Records should be witnessed and signed by another suitably trained member of staff. This will ensure a clear audit trail and ensure best practice in the management of medication. The Annual Quality Assurance Assessment for the service detailed that there had been one complaint for the service since the last visit. Records of the complaint and the action taken were not available for inspection. A record of all complaints received should be established and available for inspection, to provide information on the nature of the complaint, the action taken and the outcome. Arrangements should be made for all staff to complete Core and Safe Working Practice training at appropriate intervals. Likewise, the Acting Manager should complete a level 4 National Vocational Qualification in Care in preparation for the role of a Registered Manager. This will help staff to understand how to work safely and in accordance with best practice. 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.V349521.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.V349521.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 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. The acting manager was recommended to ensure the guide was made available in a format more suitable for the needs of people with a learning disability. It was acknowledged that the current service users may not benefit from this - but this should be considered for prospective service users. The acting manager confirmed the needs of prospective service users would be fully assessed, before any agreement would be made for a person to move into Coachmans Drive. 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. The acting manager reported that the original assessments for the two people living in the home had been archived. The acting manager was advised to ensure that an up-to-date assessment of need was in place for each person living in the home. Coachmans Drive (51) DS0000025241.V349521.R01.S.doc Version 5.2 Page 10 The Annual Quality Assurance Assessment for the service and previous inspection records confirmed that United Response had developed policies and procedures in relation to referral and assessment. Contracts were not available for inspection as they were stored at the Registered Provider’s head office in Putney. Coachmans Drive (51) DS0000025241.V349521.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 processes are in need of review to ensure the changing needs of the people using the service are recognised and planned for to promote independence, wellbeing and choice. EVIDENCE: The files of three service users were viewed during the visit. Each file contained a range of documentation including Support and Essential Lifestyle Plans. None of the documentation viewed was up-to-date and some plans were incomplete. It was noted that two of the plans were in the process of being re-written at the time of the visit however previous Essential Lifestyle Plans had not been updated following periodic review meetings. For example, one was dated 14/02/03 and another was not dated. Other supporting documentation including; communication profiles, active support guidance, listen to me workbooks, medical profiles and / or Intimate Coachmans Drive (51) DS0000025241.V349521.R01.S.doc Version 5.2 Page 12 and Personal Support records were either not dated and / or incomplete. Examples were discussed with the Acting Manager during the visit. Despite the absence of some key information, staff demonstrated a satisfactory understanding of the needs and preferences of the people using the service. Staff were observed being kind and helpful towards the people in the home during the visit. Furthermore, service users appeared relaxed and comfortable in their home environment and were seen to respond positively to staff interaction by smiling, touching, gestures and / or responsive sounds. The Acting Manager confirmed that action was taken to protect the health and safety of the people using the service. 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. 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. Advice on how to further develop the risk assessments for the use of bed rails was given to the Acting Manager during the visit. Coachmans Drive (51) DS0000025241.V349521.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 engage in a range of person-centred leisure and recreational activities, in order to lead a fulfilling lifestyle and be part of their local community. On the day of the visit one of the service users was preparing to visit a local gym with support from a community support worker and the other person living in the home was planning to go shopping for the household with another member of staff. Discussion with the manager and staff and examination of activity records confirmed service users had the opportunity to participate in leisure, recreational and community based activities e.g. voluntary work, swimming, bowling, pictures, hairdressing and personal shopping. One of the service users Coachmans Drive (51) DS0000025241.V349521.R01.S.doc Version 5.2 Page 14 was also a supporter of Everton Football Club and enjoyed attending home games at Goodison Park. Feedback received from relatives confirmed the staff team supported the people using the service to maintain links with family and friends. For example, one relative reported; “Our daughter comes home to us every weekend and a personal diary is kept of her daily activities. We use this to keep in touch with our daughter’s personal well-being and also to communicate with her carers”. Records showed that one person was also supported to remain in contact with a personal friend on a weekly basis. The Acting Manager reported that meetings were held periodically to review each person’s personal goals and aspirations. It was noted that some Essential Lifestyle Plans had not been updated following review meetings and this was discussed with the Acting Manager during the visit. At the time of the visit the home did not have a menu plan in place. Each person living in the home had a diet book with a record of meals provided. Service users were assisted by staff to prepare meals, go shopping for household products and to buy food. Appropriate support was given by staff for service users who required support with eating and drinking and specialist advice from the dietician and / or speech and language therapist was sought when required. Coachmans Drive (51) DS0000025241.V349521.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. Personal and health care records are in need of attention to evidence that the welfare of the people using the service is fully safeguarded. 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 incomplete and / or not up-to-date at the time of the visit, the Acting Manager and 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 person-centred and dignified manner. Comments received from the relatives of the people using the service included; “The care is very good”; “They do as much as we would expect them to” and “Our daughter’s special needs - personal to her only are always top priority.” Coachmans Drive (51) DS0000025241.V349521.R01.S.doc Version 5.2 Page 16 Each person using the service had a ‘Medical Profile’. Two of the three records viewed were incomplete and / or had not been kept up-to-date to provide details of medical appointments. The Acting Manager reported that both service users had access to appropriate primary health care and that arrangements were in place for service users to access the services of a general practitioner, optician, dentist, chiropodist and / or other health care professionals as and when required. Records showed that the service also had contact with the continence adviser, dietician, district nurse and speech and language therapist when required. 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. Brief local procedures had also been developed for staff to reference. 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 however there was no sample record of staff signatures. Likewise, no assessments of competency had been completed. Medication Administration Records viewed had generally been correctly completed to account for medication received and administered. Advice was given for handwritten entries on Medication Administration Records (MAR) to be witnessed and signed by another suitably trained member of staff. Furthermore, it was noted that staff had been recording bowel movement records on a MAR chart for Bisacodyl Suppositories 10m/g and it was recommended that this practice stop. Coachmans Drive (51) DS0000025241.V349521.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 Complaints procedure, which explained what people should do if they had a complaint. The procedure had also been developed in a pictorial format. Advice was given to review the procedure as reference to the National Care Standards Commission was noted. The Acting Manager confirmed that both service users and / or their relatives had been given a copy of the complaints procedure. This was confirmed via survey information and the parents of one of the people using the service reported; “We have had cause to use this procedure and it has proved very successful.” The Annual Quality Assurance Assessment for the Service detailed that one complaint had been received since the last service. No records of the date or details of the complaint had been recorded however the manager reported that the complaint had concerned the use of agency staff. Both the people living in the home appeared relaxed and comfortable in their home environment. The Acting Manager and staff demonstrated a good understanding of the communication needs of the people they cared for and the importance of observing and monitoring each person’s wellbeing, feelings and preferences by looking at body language, responses and gestures. Coachmans Drive (51) DS0000025241.V349521.R01.S.doc Version 5.2 Page 18 Staff had access to a copy of the Liverpool Inter Agency Vulnerable Adult Protection Procedures. Furthermore, the Registered Provider (United Response) had developed an Adult Protection and Prevention of Abuse and a Whistleblowing policy. Records showed that 12 of the 15 staff had completed ‘Abuse’ training and staff spoken with demonstrated a good awareness of how to recognise and respond to suspicion and / or evidence of abuse. 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.V349521.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 good. This judgement has been made using available evidence including a visit to this service. The home is pleasant and well maintained. This provides the people living in the home with a safe, clean and comfortable environment. EVIDENCE: 51 Coachmans Drive is a two-bedroom bungalow that is adjacent to its sister home, which is an identical property. The service provided has been located there for the last twenty-two years. The home had an on-going maintenance and improvement programme. Since the last inspection a new washing machine and drier had been purchased for the home and a new central heating system had been fitted. 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 systems were in place to undertake weekly, monthly, quarterly, six-monthly and annual Health and Safety checks. Coachmans Drive (51) DS0000025241.V349521.R01.S.doc Version 5.2 Page 20 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. 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. The Acting Manager confirmed that the 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. On the day of the visit the home appeared well maintained and was warm clean and tidy. Coachmans Drive (51) DS0000025241.V349521.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 adequate. This judgement has been made using available evidence including a visit to this service. Staff recruitment and training records / practices are in need of review to fully safeguard the welfare of the people using the service. EVIDENCE: 51 and 53 Coachmans Drive had been allocated a team of thirteen permanent and three relief staff to provide direct care and support to the four people (two per property) using the service. At the time of the visit there was a vacancy for one full-time employee and the Acting Manager confirmed that United Response were in the process of recruiting to the post. This equated to 3 x Senior Waking Night Staff, 3 x Senior Day Support Staff and 6 x Senior Residential Support 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 serving both 51 and 53 Coachmans Drive. The Annual Quality Assurance Assessment for the service detailed that the Registered Provider (United Response) had a policy on recruitment and Coachmans Drive (51) DS0000025241.V349521.R01.S.doc Version 5.2 Page 22 employment including redundancy. Recruitment was coordinated from the Registered Provider’s Human Resources Department. The Acting Manager reported that two new staff had commenced employment at 51 and 53 Coachmans Drive since the last visit. The files of the two employees were viewed during the visit and the following issues were noted. Both files did not contain evidence to confirm that a Protection of Vulnerable Adult and / or Criminal Record Bureau check had been completed. Furthermore, two references for one employee had been received following the date the member of staff had commenced employment. The Acting Manager reported that 7 (53.85 ) of the 13 permanent staff members 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 four (30.76 ) staff. Staff files viewed did not contain a record of training completed. Furthermore, only one of the new employees had a copy of a ‘Common Induction Standards Employee Guide’ on file and the acting manager had not signed off individual sections of the document. Staff spoken with 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. The training matrix for the staff team highlighted that some staff were in need of refresher training for some Safe Working Practice topics. Coachmans Drive (51) DS0000025241.V349521.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 good. This judgement has been made using available evidence including a visit to this service. Quality assurance systems had been developed, to monitor the conduct and management of the home. EVIDENCE: At the time of the visit, the home did not have a manager who was registered with the Commission for Social Care Inspection. The Registered Provider (United Response) had appointed Barbara Moore as the Acting Manager approximately 18 months ago. The Acting Manager reported that she had recently submitted an application to the Commission for Social Care Inspection, to register as the manager of the service. The Acting Manager was in the process of working towards the level 4 National Vocational Qualification (NVQ) - Registered Manager’s Award. Advice was given regarding the need to also complete a level 4 NVQ in Health and/or Social Care. Coachmans Drive (51) DS0000025241.V349521.R01.S.doc Version 5.2 Page 24 Records showed that Acting Manager had completed a range of training that was relevant to her role. Refresher training was needed for some Safe Working Practice training. The Acting Manager demonstrated a commitment to the ongoing development of the service and staff spoken with during the visit confirmed the manager was approachable and supportive. Comments included; “The manager is always available to speak to in between supervision meetings and is easy to approach if I have any problems relating to work” and “Our manager’s door is always open and as well as regular supervisions we can talk to her whenever we need or want.” 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. Regulation 26 visits were also undertaken by the Service Manager in addition to organisational audits. Staff meetings were held at monthly intervals. 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, with the exception of gas appliances and hoisting equipment. Fire records were viewed for the property. Records confirmed that the fire alarm system had been tested on a weekly basis. Certificates were also in place to provide evidence that the alarm system and extinguishers had been routinely serviced. Records were also checked for the gas supply and hoisting equipment as information had not been supplied prior to the inspection. Certificates were in place to confirm the heating system had been serviced by British Gas. Likewise, service certificates were available to confirm the hoisting equipment had been service by Arjo. 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. Coachmans Drive (51) DS0000025241.V349521.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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 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 3 X 3 X X 3 X Coachmans Drive (51) DS0000025241.V349521.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 (2) Requirement Timescale for action 2 YA34 19 3 YA34 19 Care plans must be kept up-todate and reflect the changing needs and personal goals of the 19/01/08 people using the service. This will help new and existing staff to understand the support requirements of the people using the service. Evidence must be available to confirm staff have commenced employment in the home 19/01/08 following the receipt of a Protection of Vulnerable Adult (POVA) check and / or a Criminal Record Bureau (CRB) certificate. This will protect the welfare of the people using the service. Staff must not commence employment at the home unless 19/12/08 two satisfactory written references have been received to safeguard the interests of the people using the service. Coachmans Drive (51) DS0000025241.V349521.R01.S.doc Version 5.2 Page 27 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 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 appropriately maintained. A record of the sample signatures of staff responsible for administering medication should be in place. Likewise, competency assessments should be undertaken periodically and handwritten entries on Medication Administration Records should be witnessed and signed by another suitably trained member of staff to ensure best practice. A record of all complaints received by the home and action taken should be maintained and available for inspection to provide evidence that complaints are appropriately responded to. All staff should complete Core and Safe Working Practice training at appropriate intervals to ensure staff understand how to work safely and in accordance with best practice. The Acting Manager should work towards a level 4 National Vocational Qualification in Care to ensure she has the necessary qualifications for her role. 2 3 YA2 YA5 4 YA9 5 6 YA19 YA20 7 YA22 8 9 YA35 YA37 Coachmans Drive (51) DS0000025241.V349521.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 L22 0LG 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.V349521.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. 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