Inspection on 31/05/06 for Collinson Court

This inspection was carried out on 31st May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 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 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Collinson Court 18/09/07

Collinson Court 02/03/07

Collinson Court 21/12/05

Collinson Court 20/06/05

Collinson Court 20/12/04

Collinson Court 05/05/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Collinson Court 56 Longton Road Trentham Stoke-on-trent Staffordshire ST4 Lead Inspector Ms Wendy Jones Key Unannounced Inspection 31 May 2006 13:30 Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 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 Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 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. Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Collinson Court Address 56 Longton Road Trentham Stoke-on-trent Staffordshire ST4 01782 658156 01782 643103 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) Autism Tascc Services Limited Ms Karenann Williams Care Home 10 Category(ies) of Learning disability (10), Mental disorder, registration, with number excluding learning disability or dementia (10) of places Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st December 2005 Brief Description of the Service: Collinson Court is a purpose-built care home, registered to provide accommodation for 10 adults. The home provides a specialist service to people with an autistic spectrum disorder. Service users’ primary diagnosis must be learning disabilities although they may have a dual diagnosis of a mental health condition. The property provides ground floor accommodation divided into four areas, each with its own entrance. These consist of two four-person apartments, two single-person flats, a staff office, training area, activity room and gym. Each apartment and flat has its own garden area and the gardens to the rear of the property are secure. The home is located off the main Trentham to Longton road; it provides off-road parking and shared drive access. The building is single-storey, providing access to wheelchair users. Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection of Collinson Court Residential Care Home, carried out over a period of three days, from the 31st May 2006. The inspection methodology included pre inspection details; service user, and relative questionnaires, discussion with social workers and the GP; inspection of the environment; discussion with service users and the manager; interviews 5 staff; inspection of care records and other documents pertinent to the inspection process. Autism Tascc Ltd a wholly owned company purchased by Craegmoor Healthcare Limited owns Collinson court. What the service does well: What has improved since the last inspection? What they could do better: Since the last inspection there was some evidence of a decline in some standards, this could be contributed to a lack of leadership as the home was without a registered manager for a period of time. Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 6 The main areas of concern were identified as the environment, staff training and skills, management arrangements for medication and the protection of service users, limited opportunities to access recreational and social opportunities out of the home. The organisation has not responded appropriately to the requirements of previous inspections and meetings with the Commission for Social Care Inspection. This was of serious concern. 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. Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 7 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 Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2. The outcomes for this standard were adequate; this judgement was based upon the information provided and a visit to the service. Service users have been assessed, but information relating to the stated purpose of the home, philosophy and the terms and conditions of residency must be made more readily available. EVIDENCE: Service users have been resident at the home for some time, therefore no new admissions since the last inspection. The services assessments of service users were detailed and provided carers with the information necessary to implement appropriate plans of care. Service users had been placed at the home following professional assessment from the County Council Specialist Placement team and in consultation with the families or primary carers. A Statement of Purpose and Service User Guide had been produced previously, but were in need of a review, as they didn’t accurately reflect the current management and staff arrangements. It was also recommended that both documents are made more readily available to staff, service users and their supporters. Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6. 7,9 The outcome for this standard was adequate; this judgement was based upon information provided and a visit to the service. Care plans were in place and were reviewed regularly, concern was expressed that staff did not have access to care planning information placing service user at risk. EVIDENCE: Care plans were in place and were reflective of the assessed needs of service users. A sample of care plans showed that regular care plan reviews had been undertaken; there was evidence of some service user involvement. Issues raised during the last inspection and in information provided since then, raised concerns regarding staff access to care plans and incidents that had occurred when care plans and risk assessments were not fully adhered to. The evidence of this visit showed that care plans were available to staff in the area of the home they worked in, they were included in the working documentation on each individuals file. Staff had easy access to this information, the issues that had occurred since the last inspection were Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 10 considered to be avoidable. The provider had been asked to investigate the areas of concern. This was a requirement of this report. Service users were allocated a key and co worker, who were a point of contact for relatives and social workers, they took responsibility for formulating care plans with the individual service users, undertook regular reviews of care plans, facilitated one to one discussions with service users on a regular basis, assisted in promoting service user independence in and out of the home, cooperated with the activities worker to offer and provide suitable social, recreational and occupational activities. Those service users spoken to and asked during this visit knew whom their key worker was. Information provided by staff and from information recorded in a communication book, showed that an incident had occurred in flat 2 resulting in damage to the fridge by a service user. The evidence of the inspection was that the incident would not have occurred if the service users care plan and measures outlined in the individual risk assessment had been followed. It was of concern that the records showed that the service user had been denied access to the kitchen as a result of the incident. The manager was asked take action to ensure that the situation was resolved and reconsider the decision to stop the service user accessing the kitchen in her apartment. The communication book is used to ensure that staff are aware of any changes and events in the home, it was of concern that the personal details of service users was recorded in this book. This was discussed with the manager. Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12- 17 The outcome of this standard was adequate. This judgement was based upon the evidence provided and a visit to the home. The opportunities to access community activities were limited due to staffing and a lack of suitable facilities. Food choice was not provided. EVIDENCE: A dedicated activity worker is employed at the home, to provide additional hours and support for service users to monitor activities, to assess the quality of experience for the individual and include plans for the day in handover. During this visit, the activity worker was interviewed and identified the need for further training in relation to suitable activities and sensory equipment. As the only activity worker, (due to a staff vacancy), she indicated that not all service users were able to be involved in a full range of activities. Improvements should be made in the range, type and frequency of service users involvement in house and community based leisure and recreational activities. The service provides a small gym; some service users have a regular programme of supervised exercise linked to health needs. There was also an activity room where individuals could be engaged in one to one activities Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 12 agreed as part of their care package and choice. The service provides two vehicles to provide service users with the opportunities to visit local community facilities and events. It was noted that one service user accessed specialist day service provision. During this visit, service users were observed, to be engaged in a number of activities of their choice. The service has also created a “sensory room”; where individuals can go to relax, listen to music etc. The room has some fibre optic lighting, had been painted to provide a relaxing colour scheme and a CD player was provided for service users to play any music they preferred. The appearance of the room was positive in some respects but would benefit from some soft furnishings and although the intention of these type of facilities was to provide a therapeutic experience, it seemed that individual service users were not engaged when in there. During this visit the communication and handover records were inspected, there was examples of personal details for individual service users were recorded in the communal communication book, the manager was asked to review this and to ensure that this practice ceases. A handover was observed in the change over from night to day staff. Information was given relating to the previous day’s report, the events of the night, anything significant that had occurred including behavioural management issues and any planned events, activities or appointments for the day. Staff worked in teams linked to each of the 4 apartments/flats. Following discussion with staff and from information provided, there was evidence that service user were supported to maintain contact with families and friends. Menus were planned based upon the known preferences of services users; choices were limited, with no alternative to the main meal provided. The cook position had been vacant for some time; this has been a requirement of previous inspections. Service users should be more actively involved in menu planning, the service should ensure that service user know what the meal choices of the day are by providing that information in each of the flats/ apartments and in a form that is understandable. Each of the units had a kitchenette area where staff could provide meals, snacks and drinks; service users were also supported to be involved in this area subject to satisfactory risk assessment. Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The outcome for these standards was poor; this judgment was based upon information provided and a visit to the service. The health needs of service user are generally well met with the need to ensure that contracted services provide the input required and that staff understood and adhered to care and action plans. Medication issues must be resolved to ensure the safety and well being of service users. EVIDENCE: The health needs of service users were met by the primary care services i.e. General practitioner and from a contract agreement with South Staffordshire health authority for the on going psychological and behavioural support for service users. During previous inspection concerns had been raised regarding the frequency of input for individuals. It was understood that resources had been restricted but these matters would be resolved in the future. A consultant psychiatrist is contracted to visit the home every two weeks to discuss specific health issues, including medication reviews. In one example of health records for service user C there was inaccurate information regarding blood pressure checks and weight management checks. The manager was asked to act on the information to ensure that all staff were Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 14 familiar with the care plan and were familiar with the specific health monitoring guidance provided. From 20/03/06 the medication supplier had changed to Boots and the system changed to a MDS, monitored dose system. For inspection purposes the medication records and stock for service users A and B were seen and a number of areas for improvement identified. The stock control instruction should be revised to ensure all staff know how often these checks are to be carried out. The records showed in one instance that stock checks of PRN meds were to be carried out on a Wednesday and Saturday, the last dated check was carried out on 20/05/06. There was a discrepancy in the number of stock recorded and the number checked during this visit. The management of information relating to medication should be revised to ensure that it is more user friendly, the current arrangements were confusing. The service should ensure that the reviews of service users medication are clearly recorded, to ensure that all staff have access to this information and information regarding the purpose and effects of medication should be readily available to all staff responsible for the administration of medication. All staff responsible for the administration of medication should sign to indicate they have read and understood the protocols in place for as required medication. Medication was secured in a lockable facility access to the medication was restricted to senior staff who had received training. Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The quality outcome of this standard was poor this judgement was based upon information provided and a visit to the home. Satisfactory complaints and VA procedures, however the service had failed to take action to investigate concerns that had been identified, placing service users at risk. EVIDENCE: No complaints have been raised with the CSCI since the last inspection, although issues have been raised with the service and with social workers. Information provided indicated that 3 complaints had been made to the service in the last 12 months, one of which was substantiated; two were in the process of being investigated. 15 reportable incidents have occurred in the period since the last inspection. Information regarding the safety of a service user compromised due to staff not adhering to risk assessments had been received. The provider was undertaking an investigation into the circumstances and will be reporting the outcome to the CSCI. Also during this visit a service user raised concern about the practice of a member of staff, this issue was raised to be investigated by the service, and a report of the outcome provide for Commission for Social Care Inspection. Staff training regarding Vulnerable adults issues has been provided in the past, the manager identified her intention to review the training needs of all staff and were necessary provide refresher training. Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24-30 The quality of this outcome standard was poor. This judgement was based upon the information provided and a visit to the home. Many environmental concerns were identified and must be resolved for the benefit of service users EVIDENCE: The service is purpose built ground floor accommodation divided into two flats and two apartments. The flats provide for up to 4 service users each, the apartments are for single occupancy. This was the first detailed environmental inspection since December 2004. The information to inform this report was from the services own audits and from inspection of all areas of the home. In the pre inspection information provided the manager indicated that since the last inspection some redecoration has been carried out in flats and apartments. Environmental issues raised during previous inspections have included poor laundry facilities; inadequate facilities for visitors to the home and issues relating to fire safety. In the last 12 months a gas installation engineer and an environmental health officer have raised concerns about the poor ventilation in the small kitchens. Ventilation was noted to be an issue throughout the home during this visit and remains a concern. Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 17 In apartment 2, which is for a single person, areas of concern included a badly stained carpet in the kitchen area, which must be cleaned or replaced with more suitable flooring. A sofa that had a broken seat must be repaired or replaced. This unit had over recent months been improved generally, but on going maintenance issues had been left to care staff to resolve and it was clear from this visit that more suitable arrangements should be made as there were areas requiring painting and general cleaning. The bedroom in this unit was quite bare but again some efforts had been made to make it a little more attractive, although it was clear that this was a work in progress and further work was required. There was some discussion regarding the shower facilities in this area and advice was given regarding how this could be improved for the occupant. At the time due to reported behavioural difficulties a showerhead had been removed and the inspector was informed that due to on-going problems it had not been replaced. Flat 2 accommodated up to four service users, each have their own bedroom and communal space is provided in an open plan lounge/dining room. Most bedrooms were inspected with the kind co-operation of the occupant, matters arising included: In one bedroom there was a very noticeable unpleasant odour, the manager stated that the carpet had been replaced with a more suitable floor covering in an effort to eliminate the problem. From observation it appeared that the wooden bed and the mattress had also been affected, the service must make further efforts to resolve this problem for the benefit of the service user. Also when checked the water supply to the hot water tap in the wash-hand basin was disconnected or had been turned off, action was required with immediate effect to resolve this. In a second bedroom another odour problem was apparent, again this must be addressed and resolved for the benefit of the service user. In all bedrooms it was clear that staff had made efforts to support service users to personalise their bedrooms as much as possible. In the corridor to the rear exit the carpet had been ripped in places and the view out of the door had been blocked with black plastic bin liners. Again action must be taken to repair or replace the floor covering in the corridor and provide a more suitable alternative to the door covering. Walls and skirting boards were scuffed or damaged and needed on going maintenance to keep them in a good state of repair. One of the sofas’s had a broken arm and must be replaced or repaired. In the bathroom and shower room a number of issues were identified including, badly maintained and broken tiles discoloured or missing seals, discoloured grouting. The bath panel was in a poor state of repair. In general the appearance of these areas could be improved to make them a more attractive and pleasant environment for service users. Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 18 In flat 1 again accommodating up to four service users each had their own bedroom and communal space was provided as before. The general appearance of this unit was better than in Flat 2 and apartment 2, furnishing and fittings were satisfactory and better maintained. Some areas of paint work on the walls needed touching up and general cleaning. The bathroom required repair and replacement to tiles, repair and replacement of seals, re-grouting badly stained grout, repainting of the path panel, repairs to the base of the shower base, remove the screws and metal bar currently fitted to the bath taps. There was an unpleasant damp odour in this area and evidence of what appeared to be mildew in some areas. This area must be redecorated to make it a more pleasant area for service users. A sensory room was located between the two flats and used for periods of time by individuals. The facility included variable lighting and music for relaxation, the facility did not include comfortable seating or did not appear to be actively used for therapeutic purposes, a service user was observed to sit on his own listening to music with no evidence of staff interaction although the door was open to enable staff to observe him easily. A review of this facility should be undertaken to provide service users with a more welcoming and comfortable environment. In addition during this inspection it was not clear if the electrical equipment used in this room had been checked recently. The exterior of the building to the rear of flat and apartment 1 had areas of badly peeling “paint”, the manager indicated that this could be caused by damp, and this was also affecting the interior of parts of the building. If as suspected this presents a more fundamental problem, the company must take action to resolve it for the benefit of service users. Staff and manager observed that the current gravel used as hard landscaping to the garden areas and front of the property had become more problematic overtime, particularly with one service user who had developed a fixation with it. It was suggested that alternative materials should be considered to make the garden areas more user friendly. A number of environmental issues had been subject to on going discussion between the CSCI and the provider, including the concerns relating to the inadequate laundering facilities, the lack of a visitors toilet and lack of sluicing facilities. It was disappointing to note that no further action had been taken following a meeting on 22 March 2006 and a subsequent letter expressing concerns that no further action had been taken. A serious concerns letter was sent separately to this report highlighting areas for immediate and on going action. Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 The quality of the outcome for this standard was poor. This judgement was based upon information provided and a visit to the home. There was a lack of training for staff and concern about the skills and experience of some staff. The levels of NVQ trained staff were low. EVIDENCE: Recruitment and retention of staff has been an issue for some time, considerable turnover has taken place in the last twelve months including senior staff. From discussion with the manager and from the evidence of recruitment records it is of concern that some staff have very little or no previous care experience or training. This does not reflect the model of service that is advertised as a specialist Autism service and potentially puts staff and service users at risk. During this visit a sample of staff records showed that most of the information required by regulation was held on each persons file. Staff training records showed deficits in training and the numbers of NVQ trained staff were limited. Staff meetings were infrequent and staff supervision was poor. The home had one vacancy for a DSF, identified as an activity co-ordinator and supernumerary to the staffing compliment, it was recommended that a more active recruitment strategy should be introduced to fill this vacancy. The Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 20 service should also give further thought to the training opportunities offered to the DSF’s, specifically around sensory equipment and therapeutic activities. Information available in pre inspection records and from the visit showed that 1277.50 hours per week were being provided. Staff were deployed to work in specific areas of the home and with specific service users. The home does not have a dedicated maintenance person; given the many environmental issues identified consideration should be given to the appointment of a person for this position. Three staff were interviewed during this visit, information relating to these interviews has been included in this report. The inspector was also present when a staff handover took place. The service provided both waking and sleep in night staff, there was concern by staff about the behaviour of one service user and the effect on the sleep in night staff who often was not able to retire until very late or not at all, this issue was discussed, the manager suggested some changes to the shift pattern’s could be made and also had made arrangements for a review of the service user. Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. The outcome for the standard is poor, based upon information provided and a visit to the service. A registered care manager application must be provided and staff must attend fire drills. EVIDENCE: The provider has recruited a new manager since the last inspection; she was employed in March 2006. An application for registration has yet to be received by the Commission for Social Care Inspection; this was a requirement of this report. Fire safety matters had been discussed at previous inspections, and issues raised relating to poor attendance by night staff in fire drills must be addressed. Information in the pre inspection questionnaire indicated that maintenance and servicing records were up to date and regular maintenance checks were being undertaken. It was of some concern that the general condition of the environment had not been addressed during these maintenance checks. Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 22 Previously Regulation 26 reports have been copied to the CSCI on a monthly basis as required by regulation, more recently reports have not been received since April 2006. Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 23 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 1 25 2 26 2 27 1 28 2 29 2 30 1 STAFFING Standard No Score 31 2 32 1 33 1 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 X LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 1 X 1 X 1 X X 2 X Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 24 Yes Are there any outstanding requirements from the last inspection? 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 YA24 Regulation 23 (2) Requirement The service must provide a visitor WC. (Previous time scale 26/04/05, 21/07/05). Timescale for action 31/08/06 2. YA30 23(2)(k), The service must provide more 16(2)(f)(j) suitable laundry and sluicing facilities. (Previous time scale 21/03/05, 21/07/05) 6 The Service User Guide must be reviewed to ensure that it provides accurate information and is readily available to service users and their supporters. The Statement of Purpose must be revised to ensure it gives an accurate account of the service and is easily accessible. The outcome of the investigation into the reportable incidents must be provided to the CSCI. (Previous timescale 21/02/06). All staff including night staff must be involved in fire drills (previous time scale 21/02/06). 31/08/06 3 YA1 30/06/06 3. YA1 6 30/06/06 4. YA42 37 16/06/06 5. YA42 23(4) 30/06/06 Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 25 6. YA27 23 Address all environmental issues in the bathrooms and shower rooms, including repairs and replacement to tiles and grouting, repaint or replace the bath panels, replace the sealing around the toilets. In addition make further efforts to create a more attractive and welcoming environment. Regulation (2). Time scale: Make efforts to ensure that the malodours in B’s bedroom are eliminated for his benefit. It was understood that the flooring had been replaced to address this issue, but due to the nature of the problem, the wooden bed base and the mattress are also affected. Address the odour problem in E’s bedroom. The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users’. The damp issues affecting the exterior of the property, and seemingly affecting the interior of the home must be investigated and action taken to resolve them. Repair or replace the two broken sofas identified during the inspection visit. Replace the water stained carpet in the kitchen area in A’s flat. Ensure that service users have access to a hot and cold water supply to their wash hand basins. 16/06/06 7. YA30 23(2) 16/06/06 8. YA35 18 31/08/06 9. YA24 23(2) 30/06/06 10 11 12 YA24 YA24 YA24 23(2) 23(2) 23(2) 16/06/06 30/06/06 31/05/06 Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 26 13 YA22 22 14 YA37 9 15 YA6 15 16 YA28 13 17 YA32 18(1)(a) 18 YA20 13(2) Investigate the complaints made by a service user, and following advice from the VA coordinator for Staffordshire Social Care Directorate. An application for registration as care manager must be completed and received by us by (previous timescale) 21/06/06. The responsible person must ensure that staff adhere to care plans and risk assessments, for the benefit of service users. The responsible person must ensure that service users are not denied access to the flat/apartment kitchens unless risk assessment has indicated an unacceptable level of risk. Staff must receive statutory training and specific training relevant to the service user group. The arrangements for the safe administration, recording, receipt and disposal must be improved to ensure the well-being and safety of service users. 28/06/06 21/07/06 07/06/06 07/06/06 30/09/06 07/06/06 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 4 Refer to Standard YA36 YA38 YA24 YA32 Good Practice Recommendations Staff responsible for the supervision of staff should be trained to do so. More frequent staff meetings should be arranged. Provide more comfortable soft furnishings in the sensory room Provide activity staff with training in appropriate activities, DS0000008324.V291468.R01.S.doc Version 5.1 Page 27 Collinson Court 5 6 7 8 9 YA14 YA7 YA24 YA24 YA33 in sensory equipment and therapy. Develop a plan, linked to the therapeutic use of the sensory room for each service user. Personal details should not be included in the communication book. Make further efforts to provide a more user-friendly garden area. Ensure that the home is maintained such away as to appear comfortable and well cared for. Consider the appointment of a maintenance person. Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 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 Collinson Court DS0000008324.V291468.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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