Inspection on 15/08/07 for Colne House

This inspection was carried out on 15th August 2007.

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

The inspector found 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Colne House 16/05/07

Colne House 23/05/06

Colne House 04/01/06

Colne House 08/09/05

Colne House 22/03/05

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Colne House 22 Manchester Road Slaithwaite Huddersfield West Yorkshire HD7 5HH Lead Inspector Alison McCabe Key Unannounced Inspection 15th August 2007 9.10am Colne House DS0000062797.V343344.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 Colne House DS0000062797.V343344.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. Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Colne House Address 22 Manchester Road Slaithwaite Huddersfield West Yorkshire HD7 5HH 01484 844775 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) Bridgewood Trust Limited Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (8) of places Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: either, whose primary care needs on admission to the home are within the following categories: Learning disability - Code Ld, Learning Disability - Code LD(E). The maximum number of service users who can be accommodated is: 8 New admissions into the home should be for service users with a learning disability who are under 65 years. 16th May 2007 2. 3. Date of last inspection Brief Description of the Service: Colne House is registered to provide accommodation and personal care for up to eight adults with learning disabilities. The home was taken over by the Bridgewood Trust in December 2004. The Bridgewood Trust is a local voluntary organisation providing a range of services to people with learning disabilities. Colne House is a substantial stone-built, three storey, detached property set in its own grounds on the outskirts of Slaithwaite, a pennine suburb of Huddersfield. Access to the property is via steps and a steep driveway. Parking is available to the rear of the property. An external lift and external steps with appropriate lighting and handrails have been installed since the last inspection to enable people with physical disabilities to access the home more easily. The current scale of charges at the home was stated to be £615.00 £1,540 per week. Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit was conducted by one inspector between the hours of 9.10am and 5.45pm. Since the last key inspection carried out in May 2007, a new acting manager has been appointed and was still in the induction period at the time of this visit. The temporary acting manager was overseeing the running of the home during this time, although since this visit was conducted, she has left the home. As part of this inspection, information has been used that has been provided by Bridgewood Trust at the request of the commission about the service, the people who live there and the staff that work there. The commission also sent out surveys to, and received responses from people living at the home, their relatives and a local doctor. Other evidence and information used has been received through notifications from the home to the commission, records of telephone contact and meetings with the temporary acting manager from Colne House and the multi-disciplinary team at Greenhead Resource Unit and information from the last inspection report. During the inspection visit the following records were examined: individuals’ care plans, risk assessments financial records, medication and associated records, daily records, accident and incident reports. Staff training and recruitment records were also seen. The inspector examined menus and records of food provided and conducted a tour of the premises. As part of the inspection visit, the inspector had discussion with the temporary acting manager, the newly appointed acting manager, a senior member of staff, two care staff and three people living at the home. Feedback from people living at the home was limited due to the nature of their learning disabilities, however the limited verbal feedback received was positive. In view of the fact that a number of people living at Colne House are not easily able to verbally express their views of the service, the inspector spent time observing care practice and interactions between staff and people living at the home. Eight surveys were returned from people living at Colne House, and all were completed with assistance from staff at the home or by staff at the home on behalf of the person. All indicated overall satisfaction with the care they received at the home. Three surveys were completed by relatives of people living at Colne House. Most comments received were positive and most expressed satisfaction with the care their relative received at the home. Comments received include, “They treat each resident individually ie. Understanding their different needs”, “When I visit they always make me welcome”, “They are very friendly and everyone always seems happy when I go to see my sister”, “Staff change over could improve. There has been two managers in about twelve months….I should have been informed there was no manager on a permanent basis”. A completed survey was received from a visiting health professional and most feedback was positive. Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 6 Since the last inspection, the temporary acting manager and the staff team at Colne House have worked hard to address the most urgent matters requiring attention that were identified. However there is still work to be done in terms of care planning and risk management in order to improve the service that people living at Colne House receive. This matter has been brought to the attention of the provider on a number of occasions. The temporary acting manager advised the inspector that the newly recruited acting manager was fully aware of the work that must be done, and that he would be reviewing all the care plans and risk assessments. The inspector would like to thank everyone for their assistance and hospitality during the inspection process. What the service does well: What has improved since the last inspection? Staff are much better equipped to support people who present challenging behaviour. Appropriate training and guidance has been provided. Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 7 Staffs understanding of safeguarding matters, or how to protect people from harm or abuse, has improved significantly since the last inspection. Policies and procedures about how to protect people living at the home have been reviewed and changed so that they reflect current good practice. Bathroom and toilet facilities on the first floor of the building have been improved. New furniture has been purchased for the small lounge making it much more comfortable. A training officer has been employed by the Bridgewood Trust. Staff are effectively meeting the needs of an individual with complex needs. Recruitment records are more thorough. Health and safety of people living at the home is much better protected than it was at the last visit through further training, guidance and support of staff and more robust policies and procedures. What they could do better: Further development of some individual care plans is necessary so that staff have clear guidance about how to support people with all their needs, including how to best manage challenging behaviours that may be presented. Identified risks to people living at the home need to be assessed properly and clear guidance must be agreed about how to minimize risks to individuals. A more person centred and flexible approach to delivering care is necessary in some areas to make sure people receive the care and support they need. Staff need to develop a better understanding of why people are taking their prescribed medications so that they can more easily monitor the effectiveness and possible side effects. More care needs to be taken in the recording of individuals’ finances to avoid errors being made. Strong and competent management of the home is necessary in order to maintain and continue with the improvements made since the last inspection. Timescales for the refurbishment and extension of the home need to be agreed. Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 8 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. Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 9 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 Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 10 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): 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples’ needs are assessed before they move into the home so that staff are aware of individuals’ needs and aspirations. EVIDENCE: Records relating to two people living at Colne House were examined and both were found to contain an assessment of need that had been completed prior to them moving into the home. Colne House DS0000062797.V343344.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 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are supported to make some choices and improvements in care planning and risk assessment have been made for some people, however some individuals’ needs are not clearly documented and some people are put at risk of harm due to lack of planning and appropriate assessment of risks. EVIDENCE: Following the last inspection and the serious concerns that were identified particularly in relation to one individual living at the home, Colne House has received significant input and support from the multi-disciplinary team at Greenhead Resource Unit in developing an appropriate care plan and behaviour management plan for an individual. Records relating to two individuals were examined. One was found to have a detailed care plan identifying most of the individual’s needs and how these should be met, although it was not clear from the layout of the file, which information was current and which was historical. The temporary acting manager agreed to re-organise the file to ensure the Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 12 most recent care plan was easily accessible to staff. It was noted however, that a new communication system introduced by speech and language therapy had not been included in the care plan, and no agreed system had been put into place to monitor whether or not it was effective. The second care plan examined contained some good information, however some elements of the care plan needed updating and further information to be added. Whilst there was good information about the individual’s personal support needs, there was no information about other needs that the individuals has. For example, there was no information about how individuals behavioural, communication, or social needs should be met. It was also noted that an element of this care plan was rather inappropriate and did not reflect a person centred approach; this was raised at the previous inspection. The temporary acting manager reported that all the care plans needed reviewing and updating and reported that the new manager would be addressing this in the near future. The format for care planning and risk assessment that is currently being used does not lend itself to clearly identifying individuals’ needs and risks to people. The current system suggests that every need a person has is a risk. The temporary acting manager acknowledged this and explained that revised systems were due to be introduced that would clearly separate risks from support requirements. Three completed surveys received from relatives of people living at Colne House all said that they believe that their relatives’ needs are being met. Since the last inspection all staff at the home have received British Institute of Learning Disabilities (BILD) accredited training in the management of challenging behaviour and physical intervention, and this is positive. A behaviour management plan has been developed for an individual, including a physical intervention plan. The physical intervention plan is also available in photographic format to assist in ensuring a consistent approach is used. Staff were observed to successfully implement the behaviour management plan during the inspection. Whilst these measures have been implemented for one individual, it was concerning that following behavioural incidents with another individual, it had been identified on two occasions on incident forms that a risk assessment and behaviour management plan were necessary. Neither had been completed. This was discussed with the temporary acting manager who gave an assurance that this would be addressed when care plans were reviewed. Records of when physical intervention has been used are not being kept in line with Department of Health guidance and it is recommended that this be introduced. Risk assessments were seen, and one was detailed and gave useful information to staff about identified risks and measures to reduce and control these risks. However, other risk assessments did not provide any useful information, and did not include risks that had been previously identified, resulting in further incidents taking place that may have been avoided. Risk management has been raised as a concern and requirement at this home at the previous four inspections. This must be addressed or the Commission for Social Care Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 13 Inspection will have no alternative but to start enforcement proceedings against the home. A requirement has been made regarding this matter. During the inspection, there were many examples of staff supporting people living at the home to make choices. This included what activities they would like to do, what to eat/drink, and where in the building they wanted to be. Staff used effective communication systems to support people in making choices. Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 14 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 who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are supported to lead active and fulfilling lifestyles, have their rights respected, keep in touch with family and friends and have a reasonably varied and nutritious diet. EVIDENCE: People living at Colne House are supported to take part in a variety of leisure and educational activities both inside and out of the home. Five individuals attend structured day services, whilst the remaining three are supported by staff at the home to lead active and fulfilling lifestyles. During the inspection, some individuals were at day services, and those that were not went shopping and out for lunch with support from staff. Staff were observed to offer people activities to keep them occupied whilst in the home. Daily records were seen and these confirmed that people continue to lead active lifestyles. Records examined indicate that people are offered support to keep in touch with family and friends. Surveys completed by relatives as part of this Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 15 inspection all confirmed that they are kept informed of important matters affecting their relative and that their relative is supported to keep in touch with them. Staff were observed to respect individuals rights and examples of this include, staff knocking on bedroom or bathroom doors before entering, offering choices about food or activities and respecting choices made by individuals. Menus were examined and showed that a reasonably varied and nutritious diet is offered. The temporary acting manager explained that she was encouraging further improvements in this area. People living at the home were observed to participate in clearing away after a meal and having some limited involvement in food preparation with support from staff. Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 16 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 who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home have their personal and healthcare needs met adequately and medicine management is good. EVIDENCE: Clear, comprehensive personal support plans are in place that describe how individuals prefer to be supported in this area. Staff were generally observed to offer discreet assistance paying attention to respecting individuals privacy and dignity. People living at this home require varied support with their personal care, although all require some assistance in this area. The temporary acting manager was observed to act as a positive role model to staff and described how she has offered advice and support to staff in this area. A healthcare professional commented in a completed survey that the service provides good support with personal care and that staff have a good understanding of individuals’ needs. There was evidence in the records that individuals’ health care needs are met appropriately. Evidence of this has also been received through notifications sent by the home to the Commission for Social Care Inspection. Since the last Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 17 inspection, an individual’s health care needs have increased and changed significantly. Staff have demonstrated sensitivity in dealing with this appropriately and ensuring that a referral to the relevant health care professionals has been made promptly. Feedback from a healthcare professional as part of the inspection process suggests that individuals’ health care needs are met and that healthcare professionals are involved in regular reviews of individuals they are involved with. Medication and corresponding records were examined. All medication was found to tally with the records kept. Medication is stored securely, and since the last inspection guidelines for the use of ‘as and when’ medication have been implemented. Staff have received training in medicine administration, and evidence of this was seen in staff training records. The temporary acting manager reported that senior staff carries out a weekly audit of medication so that any errors or discrepancies can be identified and dealt with. It is positive that since the last inspection, plans have been made to support an individual to self medicate, with support. Health care professionals have been involved in supporting the home with this. Secure storage has been installed in the individual’s bedroom, and the temporary acting manager explained that a risk assessment was to be completed before the new system would be implemented. Staff reported that the individual had been consulted throughout this process and was in agreement about self-medicating. Some of the people living at Colne House are prescribed several different medications. It is recommended that it be recorded within individuals records the reason why they are taking each medication. The temporary acting manager discovered following the last inspection that an individual was on a range of medicines and it was not possible to clarify why they had been prescribed in the first place. In order to avoid a repetition of this and to assist staff in monitoring the effectiveness of medication, further information would be useful. Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 18 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 who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Clear complaints and safeguarding procedures are in place, however where risks to individuals’ safety have been identified, appropriate steps to manage these risks are not always identified and implemented. EVIDENCE: A clear complaints procedure is in place, and information received prior to the inspection indicates that no complaints have been received by the home in the last twelve months. Relatives of people using the service who completed a survey as part of this inspection indicated that they are aware of how to make a complaint and are confident any complaints would be dealt with appropriately if necessary although none had ever had cause to complain. Since the last inspection, all staff have received training in the Kirklees multiagency safeguarding policies and procedures. Staff spoken to confirmed this and there is evidence that all staff have had individual discussion about this in their one to one support and supervision session with a manager. Each member of staff has also been given their own copy of the procedure including telephone numbers of who to contact regarding safeguarding matters. Concerns raised at the previous inspection relating to an individual’s safety and how their needs were being met, have been addressed by the home with the support from the multi-disciplinary team at Greenhead Resource Unit. The homes practice regarding referring safeguarding matters to the appropriate external bodies has improved, and this is positive. Upon examination of the Bridgewood Trust policies and procedures manual it was noted that the Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 19 procedure instructing staff what to do in the event of abuse or suspected abuse of a vulnerable adult had not been amended to ensure it is in line with the latest multi-agency guidance. The procedure described gives staff the wrong instructions about what to do in the event of a safeguarding matter arising. This was pointed out to the temporary acting manager at the time of the inspection, who immediately removed this and alerted her seniors that this should be removed from all the Bridgewood Trust homes. The Bridgewood Trust has since confirmed that this action has been taken. As previously discussed, staff have now attended training in the use of physical intervention and behaviour management, that is accredited by the British Institute of Learning Disabilities (BILD). Records of when physical intervention has been used could be improved by following the Department of Health Guidance. Behaviour management plans are now in place for an individual and staff report that these have been implemented successfully. This was observed to be the case during the inspection. As previously mentioned, it has been identified by the home that a behaviour management plan needs to be developed and implemented for another individual, however this has still not been addressed and must be completed in order to keep everybody as safe from harm as possible. A requirement has been made regarding this. None of the people living at Colne House control their own finances, as all require support in this area. The records and money kept was examined in relation to all the people living at the home. There were some minor discrepancies in monies held and not all could be tallied with the records. Although there are systems in place for checking the money against records, these had not been followed correctly and errors had occurred. This was discussed with the temporary acting manager and the new acting manager at the time of inspection who agreed that more care needed to be taken in the future to avoid further errors. Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Colne House is a spacious, clean and comfortable home. EVIDENCE: Since the last inspection new sinks and toilets have been installed on the first floor, and an additional sink has been fitted in the first floor toilet. New furniture for one of the ground floor lounges has also been purchased, making this area much more comfortable. All communal areas of the home, and one bedroom were seen on this occasion. Since the last inspection a curtain rail has been fitted in one of the shared bedrooms and a curtain to divide the room and offer privacy to the people sharing was reported by the acting manager to be on order. The home was clean and tidy and free from unpleasant odours. The acting manager reported that the Bridgewood Trust were reluctant to spend lots of money on redecoration at the moment as there are plans to refurbish and extend the home to offer single bedrooms and improved bathroom facilities. However, no timescales have been set for this work as yet. Colne House offers domestic style accommodation that is comfortable and Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 21 homely. People living at the home that were spoken to as part of the inspection reported liking living at Colne House and being happy with their bedrooms. Two bedrooms are shared, and it was recommended at the previous inspection that the compatibility of two people should be looked into. Records suggest that an individual sometimes disturbs his roommate and reference is made to this in the care plan, however the instruction to staff is “make sure I’m in bed as sometimes I mess around and disturb others”. The acting manager explained that this has not yet been explored due to other more pressing matters at the home that required her attention. The recommendation is therefore repeated. Adequate laundry facilities are available in the basement including commercial washing machine with sluicing facilities and a tumble drier. Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A skilled staff team supports people living at Colne House and the recruitment procedures have been improved to ensure that people living at the home are protected. EVIDENCE: Staff on duty during the inspection demonstrated that they had positive relationships with people living at the home. There has been a significant improvement in how staff are supporting an individual with complex needs. A staff member was observed to skilfully implement the agreed behaviour management strategies whilst supporting an individual with sensitivity and understanding. This is very positive and staff should be commended for their hard work in this area. Information received prior to the inspection indicates that of eleven care staff working at the home, seven have achieved a National Vocational Qualification (NVQ) level two or above in care, and one staff member is working towards this. The home has therefore exceeded the National Minimum Standard of at least 50 of all staff having this qualification, which is very positive. The Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 23 acting manager confirmed that all new staff completed the Learning Disability Award Framework induction and foundation before going on to complete the NVQ. Staff training records confirmed this. Feedback form a visiting professional included a suggestion that staff receive additional training, and that external trainers be accessed. Since the last inspection, the Bridgewood Trust has recruited a training officer that will be identifying training needs and arranging or providing the required training. All staff have received training in safeguarding vulnerable adults and management of challenging behaviour and physical intervention since the last inspection. Staff recruitment records were examined. Only one new member of staff has started at Colne House since the last inspection and most of the required recruitment checks were available for examination. One written reference was missing, although the temporary acting manager reported that this was at the Bridgewood Trust’s head office. Evidence that the required recruitment checks have been carried out must be available for inspection at the home. Evidence that discussion regarding gaps in employment was seen in the records and the Bridgewood Trust now has a clear system in place regarding the assessment of risk if employing staff with convictions. Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 24 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 who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Satisfactory quality assurance systems are in place, and the health and safety of people living at Colne House is generally protected, however strong, stable management of this home is necessary in order to continue to improve the service delivered. EVIDENCE: Colne House has gone through an unsettled time in respect of management. Since the Bridgewood Trust took over the home at the end of 2004, there has been two registered managers a temporary acting manager and there is a newly recruited acting manager currently going through his induction. Information received from the home prior to the inspection states that the acting manager is working on a trial basis and if he is successful at the temporary position, will be supported to get the necessary qualifications, i.e. Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 25 NVQ level four and the Registered Managers Award. The new acting manager was present during the inspection, and reported that he had previously worked at another of Bridgewood Trust’s homes as a senior care assistant, and has also worked for other organisations providing services to people with a learning disability. He is in the process of applying to become the registered manager with the Commission for Social Care Inspection. Feedback from relatives of people living at Colne House included comments that families had not been informed of changes in management. The provider should consider this during the current management changes. The temporary acting manager has worked hard to address the most urgent areas for improvement that were identified at the last inspection, and the quality of life for an individual living at the home has improved. Evidence of this was seen in records, through discussion with staff and through observation of care practice and interactions between staff and the individual. The temporary acting manager has left Colne House since this inspection was conducted. The organisation uses the ISO 9000 quality assurance system and a full audit was completed in February 2006. In addition to this formal system, feedback is sought from people through resident meetings, and questionnaires are completed prior to individuals’ annual reviews. Completed questionnaires were seen in records examined, however had not always been signed or completed in full. Provider visits are conducted monthly as required although the temporary acting manager reported that the newly appointed area managers would take over the role of conducting these visits in the near future. The health and safety of people living at Colne House is much better protected than it was found to be at the last inspection. This has been achieved through improved planning and management of challenging behaviours and staff having received the appropriate training, guidance and management. However as referred to earlier in the report, behaviour management plans and risk assessments need to be developed for an individual in order to increase protection of the individual and people around them. Information received prior to the inspection indicates that maintenance of equipment and health and safety checks have been carried out as required. Staff spoken to confirmed this. Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 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 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 1 X 3 X X 2 X Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 27 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 YA6 YA23 YA42 Regulation 13(6), 15 Requirement In order to ensure that individuals’ needs are met consistently and safely, a written plan of care must be developed that includes information about how staff should respond when challenging behaviour is displayed. 31/10/05, 28/02/06, 31/07/06 and 23/05/07 unmet. The plan must also include information about how individuals’ health, social and welfare needs are to be met. This should include information about specific communication strategies where necessary. In order to protect people from harm, unnecessary risks to the health or safety of individuals must be identified, and so far as possible eliminated. Clear risk assessments describing the risks and agreed actions to minimize the risks should be developed where necessary. Timescales of 31/10/05, Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 28 Timescale for action 30/09/07 2. YA9 YA23 YA42 13 30/09/07 28/02/06, 31/07/06 and 23/05/07 unmet. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA20 Good Practice Recommendations In order to improve monitoring of the effectiveness of medication, it would be good practice to ensure that information about why individuals are taking prescribed medication is available within their records. In order to protect individuals and ensure effective monitoring of the use of physical intervention, recording of the use of physical intervention should be in line with Department of Health Guidance. (Guidance for restrictive physical interventions. How to provide safe services for people with learning disabilities and autistic spectrum disorder) The home should ensure that the needs of those people sharing bedrooms are kept under review, so as to ensure that there is no negative impact on either person through sharing a room. 2. YA23 3. YA24 Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Colne House DS0000062797.V343344.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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