Inspection on 16/05/08 for Colin Care Home

This inspection was carried out on 16th May 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 27 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Colin Care Home 14/06/07

Colin Care Home 11/01/07

Colin Care Home 03/08/06

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Colin Care Home 19 Garlies Road Forest Hill London SE23 2RU Lead Inspector Ornella Cavuoto Key Unannounced Inspection 16th & 20th May 2008 09:30 Colin Care Home DS0000066922.V362996.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 Colin Care Home DS0000066922.V362996.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. Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Colin Care Home Address 19 Garlies Road Forest Hill London SE23 2RU 020 8699 5151 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) colincarese23@yahoo.co.uk Colin Limited Care Home 4 Category(ies) of Dementia (4), Mental disorder, excluding registration, with number learning disability or dementia (4) of places Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2007 Brief Description of the Service: Colin Care is a care home that provides long, medium and short term residential care to four men and women who have incurred a brain injury aged between 18-65. At the time the inspection was held there was one vacancy. The home is situated in a residential road close to good transport links to nearby Catford, Lewisham and Forest Hill areas. The home aims to work with service users to improve their overall quality of life and promote independence. The home is a large period property and has four large bedrooms two of which are en-suite and one bedroom is situated on the ground floor and three upstairs. There is no passenger lift within the home and so there is limited access for wheelchair users. Potential service users are given information about the service at the point when they have an initial visit to the home as part of the assessment process. Service users will be given a copy of reports issued by CSCI. Colin Care Home DS0000066922.V362996.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 was an unannounced inspection that took place over two days. Since the last inspection the manager of the home had resigned. A new manager had been recruited but had only been in post for approximately two months at the time the inspection took place. They were present for part of the first day that the inspection took place but had to leave early as they were due to commence a period of planned annual leave. The deputy manager who had in the interim period that the new manager started working at the home had acted up in the position and the owner of the home were both present for the second day of the inspection. The inspection involved speaking to two of the three people presently living at the home and also two relatives who visited the home during the inspection. In addition, two professionals and two of the support staff were spoken to. Other methods used included looking at records and a tour of the premises was undertaken. Prior to the inspection an Annual Quality Assurance Assessment (AQAA) was to be completed and returned to the Commission of Social Care Inspection (CSCI). This is a self -assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. This will be referred to within the report. Finally, as part of the key inspection process a more detailed emphasis was placed on looking at safeguarding/ adult protection as part of an investigation undertaken by CSCI into how effectively this is managed by care homes. The home has not sustained the improvements identified at the last key inspection and not all previous requirements have been addressed. This will lead to enforcement action being considered by CSCI. What the service does well: In speaking to people that live at the home and relatives comments made varied but one person at the home stated ‘It makes me happy’ regarding living at the home. A relative of another person at the home stated that when they stay with their family they always ask when they will be going home and staff understood their needs ‘ We are happy that that understanding is there’. People are supported to maintain family and personal relationships by staff at the home. The daily routines of the home are aimed at promoting individuals’ independence by encouraging them to tidy their own rooms and do their own laundry. People are offered balanced and varied meals that meet their specific cultural needs. Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 6 The home is comfortable, well maintained clean and hygienic. What has improved since the last inspection? What they could do better: The home needs to ensure that an up to date statement of purpose is drawn up that clearly defines the aims and objectives of the home and how all the needs of people living at the home are to be addressed. All people at the home need to be issued with a statement of terms and conditions with the home that they sign. Care plans should be regularly reviewed with any changes in peoples’ support needs reflected and care plans need to be signed. People at the home need to be supported to make decisions and take control of their lives by being involved in regular service users’ meetings. Clear and comprehensive risk assessments need to be drawn up for all people living at the home. All individuals need to be supported to engage in structured meaningful activities that promote personal development and also to regularly participate in the local community. Records detailing individual and group activities that people have been involved in need to be maintained. All people at the home should be given regular one to one support by staff and records of these sessions maintained. All health care needs of people at the home need to be addressed. Improvements in how medication within the home is managed are required. Complaints received by the home need to be managed more effectively and some matters in relation to safeguarding people from abuse need to be addressed. There still needs to be improvements made in the home’s vetting procedures when recruiting new staff. All staff need to be provided with regular supervision. Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 7 All aspects of health and safety must be addressed by the home. 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. Colin Care Home DS0000066922.V362996.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 Colin Care Home DS0000066922.V362996.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 People using this service experience poor outcomes in this area. This judgement has been made using available evidence including a visit to this service. The statement of purpose and service user guide for the home did not accurately reflect the home’s aims and objectives. The needs of individuals that had moved into the home had been fully assessed. Not all people at the home had a statement of terms and conditions with the home. EVIDENCE: Subject to a previous requirement that the service user guide needed to be updated to include a breakdown of the fees charged by the home and a previous recommendation that the registered provider/owner becomes familiar with the new regulation that requires this, these had both been met. However, concerns were raised at this inspection as it was identified that since the last inspection a person had been admitted to the home whose needs were not specifically addressed by the statement of purpose as although they had a mental disorder which is covered by the home’s conditions of registration they did not a have a brain injury. The statement of purpose in place stated it is the home’s aim to work with individuals that may have, for example a mental disorder or a physical disability but that has been incurred through a brain injury. Furthermore, an application to remove the present age restriction of 65 years of those people that can move into the home had been submitted to the Commission of Social Care Inspection (CSCI) as the new person that had been admitted was above this age. This would also need to be addressed in the statement of purpose. The manager stated that they were in the process of Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 10 updating the document along with the service user guide and the terms of conditions (For further details see Standard 5). However, this should have been done prior to the person moving into the home so that this information was accessible to them to enable them and the referrer to make an informed decision about the home. Shortly, following the inspection an updated statement of purpose was sent to CSCI, which did generally provide all the information required by regulation. It addressed the changes in admission criteria in respect to age. However, it was still not clear those individuals the home was aiming to support. On the page 4 of the document it states the home now ‘provides long and medium care for people with Mental Health problems and related health problems like Epilepsy and Diabetes’. It also lists ‘current diagnosis; dementia, mental health and brain injury leading to any of the above’. Having already admitted an individual with a diagnosis of mental disorder only, this indicates the home will also admit anyone with a main and sole diagnosis of dementia and although the home’s registration conditions does state dementia this was included due to the fact that the home originally presented as aiming to work with individuals with brain injury in which dementia may be an associated problem. As an individual with a main diagnosis of dementia could have potentially different care and support needs from those individuals that have dementia associated with a brain injury the home would need to clearly demonstrate how these would be met. Therefore, this needs to be clarified. Then, on page 8 it states the home ‘provides long and medium care for people with Brain Injury with associated problems like Epilepsy and Diabetes’. ‘Other diagnosis may include dementia and mental disorder excluding learning disability’. Contrary to what was written before this indicates that the home is aimed at working with individuals whose main issue is having incurred a brain injury but may have associated problems. The statement of purpose needs to be looked at again to ensure clear information is provided about those individuals the home aims to work with and how their needs will be addressed (See Requirements). As mentioned in respect to Standard 1 there had been one new admission to the home. The person’s personal file was looked at and there was evidence that their needs had been fully assessed prior to being admitted. The home had undertaken their own assessment, which included a very detailed risk assessment. Also, there was a recent Enhanced Care Programme Approach (CPA) detailing their needs and presenting risk factors as well as other reports from professionals including a psychiatric report and an Occupational Therapy (OT) assessment. There was no evidence that the person that had recently moved into the home in March 2008 had been issued with a statement of terms and conditions with the home. As mentioned in respect to Standard 1 the manager reported they were in process of updating this document. However, it would have been good practice to allow them to sign the statement of terms and conditions presently in place until a new document had been drawn up (See Requirements). Colin Care Home DS0000066922.V362996.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 &10 People using this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Not all people at the home had an up to date care plan that reflected their changing needs. Opportunities for individuals to be supported to make their own decisions were limited. Risks as part of an independent lifestyle were supported but there were not always clear risk assessments in place to ensure this was managed safely. Information about people had been kept secure and staff were clearer about their responsibilities in respect to confidentiality. EVIDENCE: At the last inspection it was identified that instead of a detailed care plan covering all needs specified within National Minimum Standards (NMS) each person had a task plan in place. These provided some background information about individuals and outlined in detail their personal care needs, preferences and daily routines. However, the plans did not provide sufficient detail around other aspects of personal support, social and health care needs. The manager at that time reported they were in the process of drawing up more detailed care plans with input from individuals’ key workers and although an example of one care plan that had been completed was seen this was not very Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 12 comprehensive. At this inspection the personal files for the three people presently living at the home were checked. There were care plans in place for all of them that covered personal and social support and health care needs but for two of the people at the home these had not been directly reviewed or updated to clearly reflect any changing needs or progress made. There was some evidence for both individuals of monthly progress reports that had been written up between July 2007- February 2008 for one person and for the other person between July 2007 –January 2008 apart from a couple months where reports had not been completed. These did cover areas relating to the care plans, for example health care, personal care, socialising and activities but there was no evidence that individuals living at the home had been consulted or that they had had an input in the monthly reports and overall the reports had addressed issues generally rather than looking at specific needs, for example for one of the individuals it was noted from records there had been some health concerns in respect to them losing weight for which they had seen the GP but there was no clear evidence of how this had been addressed or what was the outcome of this (See Standard 19 for further details). Another person at the home that was spoken to reported how they had made some positive progress in respect to their individual support needs, which was confirmed by a professional who visited the home on one day the inspection was held. Yet, this had not been clearly documented within records kept by the home. Furthermore, neither of the care plans had been signed either by the individuals themselves or a relative or a representative to indicate their involvement in the care planning process. The previous requirement specified has now been outstanding for the past three inspections. Failure to comply will lead to enforcement action to be considered by CSCI. In addition, the care plans were not accessible. They were placed in a folder that included records that were out of date and had been archived. There were separate folders used by support staff on a daily basis that included daily records, activity charts and nutrition charts. Finally, there was no evidence regular key worker sessions had been held with people at the home to discuss any aspect of their care plan or any other issues they may have wanted to raise about their support needs or living at the home (See Standard 18 for further details). In respect to the individual that had recently been admitted it was evident their care plan had been drawn up based on assessments obtained prior to their admission. However, the care plan had not been signed and there was no date when it had been completed to ensure review dates that had been specified would be implemented. There was evidence of one key work session that had been held with them since their admission in May 2008. (See Requirements and Recommendations). In relation to people at the home being supported to make their own decisions, two of them had control of their own finances One person at the home that was spoken to also related how their request to be allowed to be more independent was being supported in that they were allowed to walk to the shops unescorted and spend some time away from the home without being accompanied by support staff to have their lunch in a local café although this Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 13 had not been clearly addressed in a risk assessment (See Standard 9 for further details). Also, despite an improvement identified at the last inspection in the regularity of service users’ meetings. At this inspection there was no evidence that this had continued. The deputy manager reported that the meetings were stopped when for a period of time there were only two people living at the home and had only recently recommenced in April 2008. Yet, this left individuals with no forum to be involved and consulted in decisions that may affect them living in the home. As mentioned there was no evidence of key work sessions having been held with them either (See Requirements). Previous inspections had identified concerns about the lack of consistency in the way the home had addressed and managed risks presented by people living at the home although the last inspection found there had been some improvement in this area. At this inspection, in the main there was evidence for people living at the home that presenting risks had been addressed either as part of their care plan or within individual risk assessments. Yet, where risk assessments had been drawn up apart from the person that had recently moved into the home, these had still not been comprehensively completed. Presenting risks were not clearly or always appropriately specified nor were control measures to reduce risks, for example for the individual with whom it was agreed could go to the shops unescorted and spend time away from the home unaccompanied. Risk assessments seen within personal files had also not been reviewed or updated, for example for the person who was allowed to go out alone without staff support although there was evidence the risk assessment had been updated the most recent one dated March 2008 stated they needed to be escorted. For another person at the home individual risk assessments were last reviewed May 2007. There was a system whereby support staff were required to do a risk assessment each occasion where an incident occurred in relation to an identified risk, for example for one person they had been identified at risk of falls. However, these forms did not always appear to link in to reviewing or updating the risk assessments. The previous requirement specified in this area has been outstanding for three inspections. Failure to comply will lead to enforcement action to be considered by CSCI. Subject to a previous requirement that support staff should receive training around risk assessment and management this was partially met. The deputy manager and registered owner reported they and number of staff were undertaking a course addressing this but evidence of this was not seen (See Requirements). In relation to a previous requirement, at the last inspection although personal files belonging to individuals at the home were found to be kept in a locked cabinet when not in use it was evident that support staff that were spoken to still did not have a full understanding about their responsibilities around maintaining confidentiality and when confidentiality should be breached. At this inspection the deputy manager and two of the support staff were spoken to and all of them did demonstrate an understanding of the principles of Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 14 confidentiality. Therefore, the requirement is deemed met. However, concerns were raised that the door to the office that is upstairs where the bedrooms of two of the individuals that presently live at the home are also situated, is generally left open. Although it is acknowledged that leaving the office door open may be necessary at times, for example if a staff member is working alone in the house, potentially it allows for confidential information that may be discussed between support staff and on the telephone to be overheard. It is advised staff are made aware of this and that measures are taken to ensure confidentiality in respect to staff issues and service users is upheld at all times (See Recommendations). Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 15 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 People using this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Not all people at the home had been adequately supported to look at and engage in meaningful and fulfilling activities or to participate in the local community. There were limited opportunities for people to engage in appropriate leisure activities. Family and personal relationships had been maintained and individuals’ rights respected by staff. Meals had been provided that met with individual preferences and which people living at the home generally enjoyed. EVIDENCE: It was evident at previous inspections that not everyone at the home had been supported to engage in valued or fulfilling activities such as accessing training or education. Yet, at the last inspection some improvements were identified as having been made in this area with all individuals who were living at the home at that time attending a day centre that specifically provides support to people with brain injury. Also, one person had been supported by staff to register with a volunteer gardening project and another had enrolled with a local college to Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 16 do computer classes. At this inspection, it was evident from records and also from speaking to people who live at the home, relatives and professionals that previous improvements in this area had not been sustained. Only one of the people at the home was attending Headways twice weekly. The other person who was attending the day centre had stopped going during the latter part of last year and there was no evidence that any alternative places where they could attend or activities they could be involved in to provide some structure to their day had been looked into or that there had been any consultation with relatives or professionals involved in their care about this until recently. An annual placement review was held on one of the days the inspection was held. There was a weekly activities schedule in their personal file but this was dated May 2007 and still included their attendance at Headways. One of the support staff confirmed the chart was not being followed. A relative of the person who was involved in the placement review was spoken to and they expressed concern that they no longer attended the day centre and did not go out much. In respect to the person that had moved into the home in March 2008 there was evidence from a key work session that had been held with them that attendance of another day centre that would meet their individual support needs including being appropriate to their cultural background was discussed with them but they had refused to go. However, again there was no evidence to indicate that other alternative options had been looked into with them or ways to help them structure their days, for example it was noted that an Enhanced Care Programme Approach (CPA) review held prior to their admission had specified that leisure activities the person was engaged in at their previous place of accommodation should be continued when they moved into the home but there was no evidence that this had been supported by the home (See Standard 14 for further details) (See Requirements). Speaking to two of the people who live at the home it was evident that they were part of the local community. One of them stated that they went to a local gym twice weekly and used the local shops and had their lunch at a café on a daily basis. The other person who had been admitted a couple of months prior to the inspection being held reported they had been taken out by staff for walks to familiarise them with the immediate local area and had also attended church regularly and the local shops. Daily records seen also confirmed this. However, as mentioned above for one person at the home there was no evidence that they had any links with the local community. Concerns were expressed about this by their relative and also by a professional that was spoken to. This needs to be addressed (See Requirements). At the last inspection a previous requirement that people at the home should be provided with opportunities to partake in leisure activities inside and outside the home on an individual and group basis and a record of these should be maintained had been partially met. There was evidence that improvements had been made in this area with weekly activity schedules having been drawn up with individuals and people spoken to confirmed they had been involved in a range of different activities including going out for meals together with support Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 17 staff, being engaged in board games, using the gym. In addition, a trip to London Zoo was planned. However, records had not been accurately kept and the option of an annual holiday of people’s choice had still to be arranged. At this inspection it was identified that the developments made in this area had not been kept up. Although it was confirmed by one of the people at the home that they and another person who has since moved out were taken for a few days to Blackpool last year and there was evidence that they had a weekly activities schedule in place that did involve them partaking regularly in individual activities, for example going to the gym, swimming, watching DVDs, regularly visiting family, there was a lack of evidence that the other people within the home were involved in any leisure activities. As mentioned in relation to Standard 12 for one person their weekly activity schedule was not up to date and not being adhered to. Also, in respect to the other person that was admitted in March 2008 despite it being noted within a CPA report that they should continue with those activities they were undertaking at their previous place of accommodation, which they enjoyed specifically going swimming and attending the cinema and this had been partly addressed in their care plan, there was no evidence they had been supported to do this. Records for two people at the home detailing activities they had been involved in had not been maintained on a regular basis and no entries had been made since March and April 2008. Furthermore, daily records looked at indicated for two people that apart from playing dominoes with staff and in respect to one of them being encouraged to do some colouring and painting they had not been involved in any other leisure activities on an individual or group basis A requirement specified in relation to this area has now been outstanding for the past three inspections. Failure to comply will lead to enforcement action to be considered by CSCI. (See Requirements). In respect to respecting the rights of people living at the home and the routines of the home promoting their independence, two of them confirmed they were in possession of a key to their bedroom and also the front door. Individuals are supported and encouraged by support staff to tidy their own rooms and do their laundry. It was observed that people were allowed to choose how they spent their time in the home whether they wanted to be with other people or spend time in their rooms alone. There was evidence from records and also in speaking to people at the home and their relatives that links with family had been maintained. Relatives confirmed they regularly visited the home and that individuals living there also regularly spent time away at home with their families. Each person at the home had an individual nutrition chart in their daily files maintained by staff where meals eaten had been logged. At the last inspection a four-week rolling menu had been developed although it was evident this was not adhered to. At this inspection, although the menu plans were included in one person’s file another had their own individual menu plan. A support staff member reported these were not adhered to but used for ideas and instead Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 18 people were asked what they would like to eat. Nutrition charts did indicate that meals cooked were generally varied and balanced and that individuals’ specific cultural needs had also been catered to. A relative of one person at the home commented how they considered staff had addressed this very well. A suppertime was observed and both individuals eating appeared to enjoy the food. One of them commented that they liked the food. In respect to the other person living at the home, concerns were raised at the last inspection about their diet that was quite poor consisting mainly of snacks. At this inspection the person reported for their own personal reasons they preferred not to eat at the house apart from having sandwiches. Their relatives and professionals involved in their care were aware of this and it had been agreed since the last inspection that they could attend a café on a daily basis for their lunch, an arrangement with which they were satisfied. Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 19 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 People using this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Not all people at the home had received personal support in the way they preferred. Not all people’s health care needs had been fully addressed. Medication policies and procedures had not all been consistently adhered to by support staff to ensure people at the home were fully protected. EVIDENCE: People at the home are generally able to carry out their own personal care only requiring prompting and some supervision from support staff. Personal care needs had been addressed in care plans and people were observed as being well dressed and well groomed on both days that the inspection was held. In relation to general day- to -day support the home does operate a key worker system although it had been identified at previous inspections through speaking to support staff that they did not all have a clear understanding of their responsibilities in respect to key working and this had not been adequately addressed at the last inspection. In addition, at previous inspections people at the home had reported they were not always clear who their key worker was and that they had not received a consistent level of support although at the last inspection people spoken to reported there had been an improvement in this area and they were generally more satisfied with Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 20 the support they had received. At this inspection comments about this were more varied. One person who was admitted to the home in March 2008 was not sure who their key worker was but stated regarding staff ‘They look after me very well’. A relative of another person reported how they considered staff had a good understanding of their needs. However, one of the people stated they did not consider staff did understand their needs and they expressed concern that they had not had any individual sessions with their key worker or any of the other support staff. Records checked confirmed they had not had a key work session since August 2007. As mentioned in relation to Standard 6 there was only evidence for the person who most recently moved in that one key work session had been held with them. This needs to be addressed. Yet, in respect to staff being clear about their role as a key worker and the responsibilities this involves this had improved. Those support staff and deputy manager that were spoken to did demonstrate awareness around this (See Requirements). In relation to health care needs generally records did indicate that there had been good liaison with a range of health professionals including the GP, optician, dentist, neuro-psychiatrist, district nurse, diabetic nurse. Positively, in respect to one of the people at the home that suffers with diabetes there were guidelines included in their file regarding managing and monitoring their condition. This had also been addressed in a risk assessment. Furthermore, there were guidelines for staff in respect to individuals at the home that experience seizures with monitoring charts in place. One of the support staff spoken to, were aware of the guidelines and action to take. However, on one of the charts it stated that duration of the seizure and type of recovery should be noted in the person’s daily records and there was no evidence this had been done. Also, for the same individual an appointment to see the GP had been made due to them experiencing weight loss last August 2007 and a blood test was taken but there was no evidence that weight monitoring had been undertaken and it was not clear what was the outcome of this. Finally, one of the people at the home reported that they had been experiencing problems with their toenails, two of which were very overgrown. Yet, it was noted from their file that they had only been taken to register with a chiropodist at the end of April 2008 (See Requirements). The home uses a blister pack system for medication. Medication records for all people at the home were checked. For one person they had been issued with a photocopy of their medication record sheet when they went on social leave for them to sign that they had taken their medication, which is good practice. Yet, this had led to inaccurate recording on the main medication record. It was noted on at least one occasion staff had signed the main medication record sheet on a day that the person was on social leave and the photocopied medication record had been signed. For another person there was a gap where medication had been given but had not been signed for. In addition, it was noted for one individual that for a prescribed cream there were no instructions written on the medication record whilst for another person their medication Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 21 had not being given as prescribed. One of the three doses to be given was being administered at night rather than at teatime. The support worker with whom the medication was checked reported staff at the person’s previous place of accommodation had advised this should be done. However, this needed to be reviewed by the GP and the prescription changed. Furthermore, it was identified in respect to another prescribed medication that had run out that rather than a prescription being obtained from the GP and further supplies acquired from the pharmacist, instead this had been brought over the counter. This is inappropriate. In addition the instructions for administration written on the medication record sheet were incorrect resulting in it not being given as prescribed. Other concerns about medication included information not being specified regarding allergies on the medication record sheets, which has potential health implications for individuals. Also, the quantity of medication in packets had not all been recorded on the medication record sheets as a way of ensuring stock checks could be accurately carried out. Although amounts remaining in packets that were checked did correspond with medication that had been administered, it is advised that weekly audits of the medication should be carried out and a record of these maintained. In relation to a previous requirement that the room temperature where medication is stored should be monitored this had not been done daily as needed. Also, subject to a previous requirement that all staff should receive formal training on medication one of the support staff reported they and another staff member had completed a course provided by Lewisham Partnership a couple of days prior to the inspection being held. There was also evidence from a training matrix that had been drawn up that the other support staff including the deputy manager had been booked to attend this course within the next couple of months. One staff member who was on long term sick had been doing a long distant learning course. The registered owner reported they had completed this course but there was no evidence available to support this A requirement specified in relation to this area has now been outstanding for the past three inspections. Failure to comply will lead to enforcement action to be considered by CSCI. (See Requirements). Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 22 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 People using this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints received by the home had not all been logged and had not all been addressed in line with procedures. In the main people had been protected from abuse but action to improve the way the home manages adult protection was required. EVIDENCE: There was evidence at this inspection of a complaints policy and procedure that had recently been updated that was written in a simplified format. This had been issued to people at the home and also a copy had been placed on the notice board in the dining room. People living at the home that were spoken to were aware of the policy. At previous inspections not all people at the home considered their views had been listened to although at the last inspection people expressed they had more confidence in this area. However, at this inspection people at the home that were spoken to were both clear they would feel able to talk to the manager or staff about anything they were not happy about but they were not sure if action would be taken. One of them reported that they had not received feedback on complaints they had made in the past. A relative also reported this. The home’s complaints log was checked. There was no evidence of informal complaints having been recorded. In respect to formal complaints, two had been logged since the last inspection. The first was a written complaint by a person at the home that stated a staff member was found sleeping in the staff room when on duty and had been rude. Also, they had not been checked on as regularly as they should. In addition, there had not been adequate staff available to escort them to an activity. Although there was evidence that a statement was taken from the worker whom it was alleged Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 23 had been sleeping on duty there was no clear outcome recorded and no evidence that a formal written response had been provided to the complainant informing them of action that had been taken. In discussing the issue with the deputy manager it was established the matter regarding there not being adequate staff to accompany the person to their activity was substantiated although the other issues could not be proven. Another complaint logged by a relative also concerned a lack of staff being available to escort a person at the home to a hospital appointment and a letter from the home for the health professional not being discussed with the person themselves and the relative. Again no outcome was recorded or action taken to respond to the complainant. It was reported that the complaint was not substantiated but the result of a breakdown in communication between the staff and the relative whom it was thought was going to accompany the person to the appointment and the letter was actually for the person to read. A further complaint was reported at the inspection whilst a person at the home was spoken to in which it was again alleged that another staff member had fallen asleep on the train whilst accompanying them out in the community. This had not been logged and there was no evidence of action taken to address the matter. The deputy manager reported that the staff member was spoken to who denied the allegation and there was a lack of evidence to substantiate the matter (See Requirements). Subject to a previous requirement that all staff should undertake formal training in relation to adult protection this was identified as met at this inspection. There was evidence that all support workers had undertaken training via Lewisham Partnership and also had training in -house. Overall, the two support staff spoken to demonstrated good knowledge about different types of abuse and also reporting procedures in relation to if they were informed by a person who uses the service that they were a victim of abuse or witnessed an incident that they considered was abusive. In respect to the deputy manager they were not completely clear about their responsibilities if in charge and they were informed by a person at the home of an incident relating to adult protection or that they witnessed an incident themselves. There was evidence they had previously undertaken training but it is advised they attend a course specific to addressing duties of managers in relation to adult protection procedures. The home had an adequate policy on whistle blowing that support staff were aware of but the adult protection policy was very general and needs to be reviewed to ensure it is more specific to the home, for example who should be contacted within the local authority in the event of having to report an incident. Finally although, people at the home spoken to were happy to talk to the manager or any of the staff if they did not feel safe it was evident they were completely clear of support available outside of the home, for example being able to talk to an advocate, being aware of CSCI if they did not want to talk to anyone at the home in the event of being a victim of abuse. It is advised this is addressed (See Requirements and Recommendations). Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 24 Since the last inspection there has been one adult protection investigation in relation to the home regarding an allegation against the manager who was working at the home at that time. This was not substantiated. Shortly following this inspection CSCI was alerted by the local authority about an allegation that had been made against a staff member working in the home. Action that had been taken to address this was not known at the time of writing the report. The home does not have responsibility for managing any of the finances of people at the home. However, in discussions with the registered provider/ owner and deputy manager about what individuals have in place for keeping their money safe, it became evident that it was not known how one particular individual accessed their money from the bank whether they used a cheque book or a cash card and if so whether they used a pin number and how they kept this safe so they were not at risk of financial abuse. This needs to be addressed (See Requirements). Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 25 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): 24,28 &30 People using this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is homely, comfortable and well maintained. There are adequate communal spaces that supplement individuals’ rooms. The home was clean and hygienic. EVIDENCE: The home is a large period property that has been decorated to a good standard with neutral colours being used throughout and there is laminate flooring all the way through the home making it bright and airy. Furnishings are domestic in nature making the home comfortable and homely and it has access to local amenities, local transport and relevant support services to suit the personal and lifestyle needs of people living at the home. Overall, it is suitable for its stated purpose. In relation to communal spaces the home has a spacious lounge. There are French doors with steps leading to the garden, which is well maintained. There is also a separate dining room and a kitchen that is domestic in nature. Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 26 The home was clean and hygienic on the day the inspection was held. There are adequate laundry facilities sited away from the preparation of food. Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 27 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 &36 People using this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Support staff had achieved or were in progress of achieving a relevant qualification. Staffing arrangements were not always adequate to ensure the safe and efficient running of the home. Recruitment practices had not fully protected people living at the home. Not all staff had received an induction but generally training needs were being addressed. Support staff had not still received sufficient supervision. EVIDENCE: It was reported that the deputy manager and two of the support staff had completed a National Vocational Qualification (NVQ) Level 2 whilst another had a BTEC Diploma in Care and a staff member recently recruited was a qualified nurse. In addition, two of the support workers were due to commence studying for a NVQ; one to do a Level 2 and the other a Level 3 the following day after the inspection was held. This meets with National Minimum Standards (NMS) that 50 of staff should have completed or be working towards a relevant qualification. At the last inspection concerns were identified about a lack of clarity regarding information provided by individual support staff about the NVQ qualifications they had completed and those they were in the process of undertaking. As a result it was required that evidence be obtained regarding Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 28 this. Shortly, following the last inspection evidence was sent to CSCI about qualifications completed and those in the process of being undertaken for all staff apart from one. At this inspection it was reported that this person was one of those staff shortly to commence a NVQ Level 2. Furthermore, at this inspection copies of certificates relating to NVQ or equivalent qualifications were seen in the personnel files for support staff apart from the newly recruited worker. As part of the recruitment process this should be obtained. The deputy manager’s personnel file was not available for inspection and therefore it could not be checked whether a copy of their certificate was on file (See Standard 34 for further details). There was evidence of a rota being maintained. However, the first day the inspection was held the manager reported that they were due to leave early to commence a period of leave but on checking the rota there was no evidence of on- call management arrangements having been put in place for staff in case of an emergency and/or in need of support. Staff do work alone in the home. On discussing this with the manager, it was identified that the deputy manager was on annual leave and the registered owner / responsible individual would not be available till after the weekend. Concerns were raised that on the rota only one support worker would be on duty during the day and evening over this period and this was considered inadequate cover given the lack of on –call support. As a result the manager did arrange for an additional support worker to work on each shift over the weekend. However, this needs to be addressed and management on –call arrangements must be clearly specified on the rota at all times. In relation to a previous requirement that the home needed to ensure that the skill mix of staff working at the home was more balanced to include a sufficient number of suitably qualified and experienced staff this was assessed as met at this inspection. The last inspection raised ongoing concerns that a number of the support staff spoken to lacked knowledge in key areas including confidentiality, adult protection, dealing with challenging behaviour and how to deal with emergencies. This was despite the previous manager reporting that they had provided internal training in these areas. However, at this inspection support staff and the deputy manager that were spoken to were able to demonstrate a clearer understanding of these issues although as mentioned in respect to Standard 23 the deputy manager needs to be more aware about their responsibility in respect to adult protection from a management perspective. Also, there was evidence that in the main the other training needs of support staff were being addressed (See Standard 35 for further details). Therefore this requirement is deemed met. In respect, to a previous recommendation that the home should consider employment of bank staff to alleviate pressure on permanent staff to cover shifts during sickness and annual leave one worker had been employed on this basis and it was specified within the home’s AQAA that measures were being looked into to address this although it was noted from the rota that staff were not working too many hours (See Requirements and Recommendations). Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 29 In terms of recruitment the personnel files of all the support staff presently working in the home were checked. Two of these files belonged to individuals that had been recruited since the last inspection with one having commenced working at the home recently whilst the other had been working at the home for the past few months. At the last inspection it was identified that all staff had the necessary checks and documents required including Enhanced Criminal Record Bureau (ECRB) checks, two references and appropriate identification. There were also records of the interview process carried out with individuals but gaps in employment were noted that had not been adequately addressed. At this inspection for the most newly recruited staff member there was no evidence of a completed application form or of the interview process they underwent. Consequently, details of their work history and if there were any gaps in employment could not be checked. There was only one reference included in the file although appropriate identification documents were in place. Copies of any qualifications attained were not on file. Also, there was no evidence that an up to date Enhanced Criminal Record Bureau (ECRB) check had been obtained although a check (POVA First) against the Protection of Vulnerable Adults list, which includes the names of persons deemed unsuitable to work with vulnerable adults had been done. Shortly following the inspection evidence that an up to date ECRB had been obtained was provided to CSCI although none was sent in respect to the other missing documentation. In respect to the other new staff member although all necessary checks and documents were included in their file it was noted that a POVA First check had not been obtained till approximately a month after their start date as specified on their employment contract. An ECRB from a previous employer was on file and it was evident that they had been allowed to commence work at the home based on a portable ECRB. This is not permissible. It was also identified that there were gaps in their employment that had not been accounted for although there was evidence of the interview process and that they had been interviewed by two staff members as previously recommended. The personnel files for the new manager and the deputy manager were not available for inspection. The registered owner/provider reported they were kept at different premises. Copies of references and evidence that an ECRB had been obtained for the deputy manager was sent to CSCI but the date of the ECRB was approximately 6 months after the deputy manager reported they had started work at the home. These staff files would need to be checked at the next inspection (See Requirements). A training matrix had been drawn up by the manager that had included all mandatory training topics such as food hygiene, fire safety, first aid amongst others to be completed by staff and also specific training, for example mental health, managing diabetes, mental capacity, managing challenging behaviour and others to address individual and collective needs of people at the home. Dates of courses some of which were to be provided by Lewisham Partnership that had been booked for staff to attend were specified on the matrix. This meets a previous requirement specified in this area. However, although it was noted that all staff had been booked to complete a course in mental health Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 30 which would increase their awareness around working with the presenting needs of some people living at the home and also there was evidence that some support staff had completed other relevant training provided in house that addressed managing challenging behaviour and epilepsy around which support staff spoken to were more knowledgeable, there was still no evidence that any specific training had been arranged with Headways about working with people with brain injury. It was reported at the last inspection this was in the process of being arranged but this had not been included in the training matrix. This needs to be addressed. Also, despite it being reported at previous inspections that all support staff despite how long they had worked at the home had been inducted using Common Induction Standards (CIS) as another means of assessing and improving their knowledge base around the principles of care there was no evidence of this. At this inspection, only one of the support worker’s personnel file included evidence that they had completed an induction in line with CIS. Furthermore, in respect to the two staff recruited since the last inspection there was only evidence for one of them that a basic initial induction had been completed. A CIS work booklet was also included within their personnel file but this had not been completed (See Requirements) Subject to a previous requirement that all staff should receive at least six supervision sessions annually as specified within NMS this had not been addressed at this inspection although there was evidence that the new manager had begun to drawn up supervision contracts with the support staff. There was evidence of annual appraisals and personal development plans having been completed last year with support staff regardless of whether they had worked at the home for a year although the information provided in these was limited (See Requirements). Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 31 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 People using this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The lack of stable management has affected the overall running of the home. The views of people living at the home have not regularly been sought as part of self -monitoring. Not all areas of health and safety had been adequately attended to, to ensure people at the home were fully protected. EVIDENCE: Since the home opened in 2006 four managers have been recruited to work at the home. The last manager resigned in December 2007 An application to become registered was not submitted. In the interim period that another manager could be employed the deputy manager acted up in the position with support from a management consultant. The new manager only commenced working at the home on March 25th 2008. They do not have any experience working with individuals with a brain injury. Yet, they have previously worked as a registered manager in a home for people with learning difficulties and associated mental health problems. Consequently, they do have the necessary Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 32 skills and experience to ensure the home is well run. Also, although they do have transferable knowledge, experience and skills having worked with people with learning disabilities it is advised they undertake some specialist training in relation to working with people with brain injury to be clear about how to support people living at the home with these needs and also to help support staff. They reported in the home’s AQAA (Annual Quality Assurance Assessment) that they intend to undertake the Registered Manager’s Award within the next 12 months but an application for registration had not yet been submitted. It is advised this is done as soon as possible. It was evident at this inspection the lack of continuous and stable management has had a detrimental affect on the day to day running of the home with many areas not meeting with NMS and resulting in previous requirements identified as not met (See Requirements in respect to Standards 6,9,14,18,20,34,36& 39). There was some evidence that the new manager is beginning to address issues, for example with the introduction of a new comprehensive preadmission assessment, new format for care plans and risk assessments and gaps in training for support staff beginning to be addressed and also supervision. The manager had also outlined plans to improve the management and running of home within the AQAA although some discrepancies were identified in respect to information detailed within the self- assessment document (See Standard 39 for further details). However, failure to comply with requirements will lead to enforcement action being considered by CSCI and the registered provider/owner needs to ensure that the home is effectively managed at all times and in all areas (See Requirements). In respect to a previous requirement that the home should ensure an effective quality assurance system is developed that includes the views of people living at the home, relatives and professionals with links to the service being regularly sought as part of self -monitoring, this had still not been addressed. At the last inspection it was identified that customer satisfaction surveys for two of the three people living at the home at that time and also relative surveys had been completed but the results of these had not been outlined in a report, which should be made accessible to all individuals involved and CSCI should also be informed of these. Furthermore, a development plan in which aims and outcomes for people at the home based on the results of surveys had not been drawn up. At this inspection, there was no evidence that any further action to meet this requirement had been taken including any further surveys being completed. This has now been outstanding for the past three inspections. Failure to comply will lead to enforcement action to be considered by CSCI. Also, contrary to the information provided in the AQAA that ‘monthly service users’ meetings are held..’ and ‘service users are enabled to have regular key work sessions which are recorded..’ both ways in which feedback about the service could be sought, as stated in relation to Standards 6, 7 and 18 there was a lack of evidence that either had been carried out on a regular basis since the last inspection. However, in general the AQAA had Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 33 been completed to a satisfactory standard. Also, evidence of monthly provider reports had been sent to CSCI (See Requirements). In relation to health and safety previous requirements in relation to the home needing to have a fire risk assessment and a building risk assessment had been met. Both documents that were dated 15/08/07 and 19/11/07 respectively were comprehensive. However, a requirement that alarm call points should be tested weekly had not been met. The records detailing the fire tests and drills were not available when the inspection was held. Neither the deputy manager nor the registered provider/ owner was able to locate these records. However, photocopies were sent to CSCI shortly following the inspection. It was evident from these that the fire tests had not consistently been carried out weekly as required. In addition, although fire drills had been undertaken generally quarterly and sometimes more frequently it was noted that two staff members that have worked at the home for some time had not been involved in a fire drill. This needs to be addressed with all staff members being involved in at least one fire drill within a year. Furthermore, in respect to maintenance of fire equipment including emergency lighting, the home’s AQAA stated a check had been done in February 2008 but documents seen at the inspection indicated a check had last been done in February 2007. Following the inspection the registered provider/ owner stated that external contractors had visited the home in November 2007 to test the fire alarm but no evidence of this was provided. Consequently, it was not clear that the home’s emergency lighting had been checked. There were up to date maintenance certificates for gas safety, electrical wiring and Portable Appliances testing (PAT) (See Requirements). Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 34 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 1 2 3 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 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 3 LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 2 X X 2 X Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 35 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 YA1 Regulation 4 Requirement The registered provider must ensure that there is an up to date statement of purpose that fully outlines the aims and objectives of the home stating specifically and clearly those individuals that are to be admitted. Also, how the needs of all those who use the service would be addressed to provide agencies/prospective people who wish to move in clear information about the home. The registered provider must ensure that a comprehensive care plan is drawn up in consultation with all people at the home, their relatives or a representative where appropriate and the person indicating their involvement signs this. (Previous timescales of 31/01/07, 31/07/07 DS0000066922.V362996.R01.S.doc Timescale for action 31/08/08 2. YA6 15 31/08/08 Colin Care Home Version 5.2 Page 36 3. YA6 15(2) 4. YA7 12(2) 5. YA9 13 (4) (a) &(b) &30/09/07 partially met) Failure to comply with requirements will lead to enforcement action being considered by CSCI The registered provider 31/08/08 must ensure that following reviews or reassessment of individuals’ needs that any changes in support are reflected within their individual care plans so that progress can be monitored and evaluated. (Previous timescales of 31/07/07 & 30/09/07not met) 30/09/08 The registered provider must ensure that regular opportunities are provided to people at the home to partake in a forum specifically service users meetings to involve them in decisions about the running of the home that may affect them as part of supporting them to take control of their lives. The registered provider 31/08/08 must ensure that all people at the home have a comprehensive risk assessment in place that addresses all identified risks presented by individuals and control measure/ action is specified on how risks/hazards are to be reduced. (Previous timescale of 31/01/07,31/05/07 &30/09/07 partially met) Version 5.2 Page 37 Colin Care Home DS0000066922.V362996.R01.S.doc 6. YA9 18(1)(c)(i) 7. YA12 12(1)&16(2)(n) 8. YA13 16(2)(m) 9. YA14 16(2)(n) Failure to comply with requirements will lead to enforcement action being considered by CSCI The registered provider must ensure all staff working at the home receives training around risk assessment and management. (Previous timescale of 31/07/07 & 30/11/07 not partially) The registered provider must ensure that all people that live at the home are supported to engage in appropriate structured activities that are meaningful and fulfilling as part of maintaining their welfare and for their personal development. The registered provider must ensure all people living at the home are provided with regular opportunities to be part of and engage in the local community as part of maintaining their welfare. The registered provider must ensure that all people at the home are provided with an activities programme that involves them partaking in activities both inside and outside the house on an individual and also a group basis and a record of activities that individuals are involved in is maintained. (Previous timescale of 31/03/07 not met 30/09/08 30/09/08 30/09/08 31/08/08 Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 38 10. YA18 12 11. YA19 12(1) 12. YA20 13(2) Timescale of 31/07/07 & 30/09/07 partially met) Failure to comply with requirements will lead to enforcement action being considered by CSCI The registered provider 31/08/08 must ensure that all staff provides a consistent level of support to all people at the home and that they are all clear about their role as a key worker and the responsibilities this involves. (Previous timescale of 31/07/07 &30/09/07 partially met). The registered provider 31/08/08 must ensure the health care needs of all people at the home are fully addressed as part of maintaining their welfare. The registered provider 31/08/08 must ensure that all staff receives training around medication that meets with the specifications of standard 20:10 within the national minimum standards and in future all new staff must receive this training prior to being allowed to administer medication. (Previous timescale of 31/03/07 not met Timescales of 31/07/07 &30/11/07 partially met). Failure to comply with requirements will lead to enforcement action being considered by DS0000066922.V362996.R01.S.doc Version 5.2 Page 39 Colin Care Home CSCI 13. YA20 13(2) The registered provider must ensure that the room temperature where medication is stored is monitored daily and recorded to ensure it does not exceed the recommended level of 25c. (Previous timescale of 30/09/07 not met) The registered provider must ensure that all instructions for administration for medication are written correctly on the medication record sheets and medication is given as prescribed to ensure the health and welfare of people at the home is maintained. The registered provider must ensure that information regarding allergies for people that live at the home is recorded on the medication record sheet to ensure the health and welfare of people at the home is maintained. The registered provider must ensure that quantities of all medication kept within in the home is recorded on the medication record sheet to enable accurate stock checks to be undertaken. Also adequate supplies of all medication prescribed to people at the home are kept at the home at all times as part of DS0000066922.V362996.R01.S.doc 31/08/08 14 YA20 13(2) 31/08/08 15. YA20 13(2) 31/08/08 16. YA20 13(2) 31/08/08 Colin Care Home Version 5.2 Page 40 17. YA22 22(3) &(4) 18. YA23 13(6) 19. YA33 18(1)(a) 20. YA34 19 & Sched 2 maintaining individuals’ health and welfare. The registered provider must ensure that all complaints made by people at the home, relatives or representatives are logged and that action taken to investigate these and the outcome is clearly recorded and the complainant is informed of this as part of maintaining individuals’ rights and protection The registered provider must ensure that the home’s adult protection policy and procedures are reviewed and this is made more specific to the service as part of protecting individuals at the home from abuse. Also, that staff are clear about how people at the home manage their own finances to ensure any risk of financial abuse is minimised. The registered provider must ensure that clear arrangements for management cover for the home are in place at all times and that staff working at the home are aware of these as part of maintaining the health and safety of people at the home and the staff that work there. The registered provider must ensure that adequate vetting procedures are used when recruiting staff to work in DS0000066922.V362996.R01.S.doc 31/08/08 31/08/08 31/08/08 31/08/08 Colin Care Home Version 5.2 Page 41 21. YA34 19 & Sched 2 22. YA35 18(1)(c)(i) 23. YA36 18 (2) 24. YA37 10(1) the home specifically that a full employment history is obtained and any gaps in employment are explored and accounted for. Also, that a record of the interview process carried out with staff is maintained. (Previous timescales of 31/07/07 &30/09/07 partially met) The registered provider must ensure that all checks and documentation specified under Schedule 2 in relation to recruitment are obtained prior to allowing staff to commence working in the home for the protection of individuals that live at the home. The registered provider must ensure that all staff working at the home receive training to ensure all the needs of people at the home specifically those with brain injury can be effectively met. The registered provider must ensure all individual staff receives at least six supervision sessions annually and records of the sessions are maintained. (Previous timescale of 31/07/07 & 30/11/07 not met). The registered provider must ensure that all areas of the home are managed effectively and safely for the protection and welfare of the people that live at DS0000066922.V362996.R01.S.doc 31/08/08 31/08/08 30/09/08 31/08/08 Colin Care Home Version 5.2 Page 42 the home. 25. YA39 24 The registered provider 31/08/08 must ensure that the quality assurance systems for the home are developed. An effective system where service users ‘ views underpin all selfmonitoring, reviews and development of the home. (Previous timescale of 31/05/07 not met. Timescale of 31/07/07 partially met. Timescale of 30/09/07 not met) Failure to comply with requirements will lead to enforcement action being considered by CSCI The registered provider 31/08/08 must ensure that fire alarm call points are tested weekly to ensure the health and safety of people at the home is maintained. (Previous timescale of 30/09/07 not met) 31/08/08 The registered provider must ensure that all staff working at the home are involved in at least one fire drill annually. Also that there is evidence that all fire equipment specifically the emergency lighting is maintained as part of upholding the health and safety of people at the home. 26. YA42 23(4)(c)(v) 27. YA42 23(4)(c)(iv) &23(4)(e) Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 43 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. 2. 3. Refer to Standard YA6 YA10 YA23 Good Practice Recommendations The registered provider should try to develop the role of the key worker further to involve them in the drawing up and reviewing of care plans. The registered provider should try to make the staff aware of keeping the office door closed whenever issues of a confidential nature are to be discussed. The registered provider should try to ensure the deputy manager undertakes a course that specifically addresses their responsibilities as a manager in respect to adult protection. The registered provider should try to ensure that people at the home are aware of all external support/ professionals they can contact in the event of being a victim of abuse and not feeling safe in the home as part of ensuring they feel protected. The registered provider should consider the employment of bank staff to alleviate the pressure from the permanent staff to provide cover for annual leave and sickness. The registered provider should try to ensure that the new manager submits an application for registration as soon as possible. 4. YA23 5. 6. YA33 YA37 Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 44 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Colin Care Home DS0000066922.V362996.R01.S.doc Version 5.2 Page 45 - 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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