Inspection on 16/05/07 for Colne House

This inspection was carried out on 16th May 2007.

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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Colne House 15/08/07

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 16th May 2007 11:00 Colne House DS0000062797.V333383.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.V333383.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.V333383.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 Mrs Elizabeth Mary Wickenden 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.V333383.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. 23rd May 2006 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 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 - £1,540.00 per week. Information provided to CSCI by Bridgewood Trust prior to the inspection states that additional charges are made for the following: Activities, hairdressing, toiletries, newspapers, and holidays which are subsidised and do not include staff costs. The service provider ensures that information about the service is available to prospective and current people living at the home by way of the home’s Statement of Purpose, the Service User Guide and through CSCI inspection reports. Colne House DS0000062797.V333383.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 11am and 8.20pm. Since the last key inspection carried out in May 2006, the acting manager has left the home and a temporary acting manager has been brought in to oversee the running of the home from another Bridgewood Trust 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, staff training records and menus, records of telephone contact with the ex acting manager 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 in addition to staff rotas. 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 acting manager, three staff members 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. Two surveys were returned from people living at Colne House, and both were completed with assistance from staff at the home. Both indicated overall satisfaction with the care they received at the home. Four surveys were completed by relatives of people living at Colne House. All comments received were positive and again all expressed satisfaction with the care their relative received at the home. Comments received include, “I know that ***is happy and with support is able to enjoy her life and still see family also”, “I think they care for *** very well and give all the support she needs to be happy”, “They treat each resident as an individual and meet each residents requirements. They are kept clean, are happy and well fed. There is always a warm welcome when my husband and I visit. The staff are very good”. A completed survey was received form a local doctor and again all feedback was positive. A number of areas of concern have been identified at this inspection visit, mainly around the protection of the people at the home, and practice in respect of the home notifying the appropriate authorities of protection matters. Colne House DS0000062797.V333383.R01.S.doc Version 5.2 Page 6 It was also found that essential training had not been delivered to staff, and that some areas of record keeping were poor. A letter of concern was sent to the provider on the 18th May 2007 detailing matters that required urgent attention. Since the inspection visit two meetings between the provider, CSCI and the local authority have been held to agree a strategy for ensuring the protection of all the people living at Colne House. A number of requirements have been made following this inspection, and those in the letter of the 18th May 2007 are included in this report. It must be noted that the provider has already taken some steps to address the areas that require urgent attention, and has been cooperative throughout this process. 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? People living at the home take a more active role in the preparation, and clearing away of meals. Colne House DS0000062797.V333383.R01.S.doc Version 5.2 Page 7 The ground floor flat has been refurbished for one of the people living at the home providing a private bathroom, lounge and bedroom. A stair lift has been installed so that those people with mobility difficulties can access the first floor more easily. Staff are now monitoring hot water temperatures on a regular basis to ensure that these are maintained at the required temperature. What they could do better: Further development of individuals care plans is necessary so that staff have clear guidance about how to support people with all their needs. 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. Staff need guidance and training about how to appropriately manage challenging behaviour using positive approaches in order to support and protect people. 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. Clearer guidance must be given to staff about when to give emergency medication so that people living at the home have their safety and well being protected. Procedures and practice in terms of protecting people living at the home need significant improvement. Bathroom facilities need modernising and improving, as they are dated and shabby. Some aspects of staff recruitment practice need to be improved so as to make sure that people living at the home are protected form potential harm. Monthly visits conducted by the provider need to be improved to ensure that areas for further development or poor practice are identified and appropriate action is taken. A suitably qualified and experienced manager needs to be recruited. Colne House DS0000062797.V333383.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.V333383.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.V333383.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. Two people living at the home were able to complete a survey with staff support as part of this key inspection. Both indicated that they had received enough information about the home before moving in, and one added that he had two visits before a decision was made. Colne House DS0000062797.V333383.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, however individuals’ needs are not met consistently and people are put at risk of harm due to lack of planning and appropriate assessment of risks. EVIDENCE: Two care plans were examined, and whilst there has been some development of these since the last inspection in that individuals’ personal care needs are described in detail, there was no information about other needs that individuals’ have. 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 an individual’s care plan was rather inappropriate and did not reflect a person centred approach. This was pointed out to the temporary manager at the time of the visit. A personal support plan assessment has been completed in respect of people living at the home. This contains some excellent information about peoples needs and aspirations, Colne House DS0000062797.V333383.R01.S.doc Version 5.2 Page 12 however very little of the information has been used to develop a care plan so that staff are clear about the best way of supporting individuals. There is evidence that reviews take place, but evidence in minutes of reviews suggest that they do not always reflect the true picture of how an individual is getting on at the home. It was concerning that no behaviour management plan was in place for an individual who needs significant support in this area. Records suggest that physical intervention is used. There is no agreed physical intervention plan, and staff have not received training in this area. It is essential that planned strategies be put in place to ensure that the individual receives consistent care delivered safely and by staff that have the appropriate skills and experience. During the visit, staff were observed to offer people living at the home choices about a range of things. For example, people were asked what they would like to eat, drink, if they would like to go out etc. Two individuals completed a survey as part of the key inspection (with staff support) and both indicated that they could make choices about how they spend their time. Due to the level of learning disability of most of the people living at Colne House, significant support is required to support people to make decisions about their lives. Risk assessments, for example to assess people’s likelihood of falling, likelihood of taking an inadequate diet, etc., are in place in individuals’ records. These did not provide useful information about the nature of the assessed risk and did not give guidance to staff about what steps should be taken to minimize the risks. Risks that were identified by the inspector during the visit, through discussion with staff or entries in individuals’ records, had not been assessed, resulting in unnecessary risks being taken and people living at the home not being protected adequately. For example, entries relating to unsafe behaviour in the kitchen on more than one occasion had not been appropriately risk assessed, and therefore no steps to minimize the risks had been agreed. A number of incidents of people living at the home being physically harmed by another individual living at the home have occurred, however appropriate measures to reduce these risks had not been agreed. Colne House DS0000062797.V333383.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 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 Colne House are supported to lead active lifestyles, keep in touch with friends and family and have a reasonable healthy diet. EVIDENCE: People living at Colne House are supported to take part in a range of leisure and education based activities both in and out of the home. Of eight people living at the home, five have regular day service provision ranging from three to four days per week. The remaining three people stay at home and are supported by staff at the home to access the community or take part in activities at the home. This was confirmed in the records examined. Staff were observed to encourage people at home to participate in meal preparation and domestic tasks, and a staff member supported individuals with nail care. Four surveys were completed by relatives of people living at Colne House, and all indicated that they were kept informed of important matters affecting their Colne House DS0000062797.V333383.R01.S.doc Version 5.2 Page 14 relative. One commented that staff support their relative to visit them at their home, as they are unable to make the journey to Colne House. Another said, “ If there is a problem they always call to let me know”. Records examined confirm that good support is offered to individuals to keep in touch with family and friends. Through observation of care practice, there was evidence that staff respect peoples rights and promote individual choice and freedom wherever possible. Staff were observed to knock on bedroom/bathroom doors before entering, and to interact with people at the home and not exclusively with each other. It is positive that staff have maintained this improvement since the last inspection visit. Menus submitted to the commission before the inspection suggested that a reasonably varied and balanced diet is offered. On the day of inspection, the evening meal was pizza and potatoes wedges with salad, followed by yoghurt or fruit. A member of staff said that staff would also cook fresh meals from scratch. Records of food provided did not demonstrate that the recommended five portions of fruit or vegetables had been offered, and this should be monitored to ensure that people are being offered a healthy and balanced diet. Staff were observed to eat their meal with people living at the home and this is good practice. The meal was unhurried and informal and some of the people chose to participate in clearing up. The temporary manager reported that she is encouraging staff to support individuals to be more actively involved in food preparation and clearing away. Colne House DS0000062797.V333383.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 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. In general, people living at the home have their personal and healthcare needs met adequately and medicine management is generally good, however in order to protect all people living at the home from harm, improved practice in the monitoring of injuries sustained and clearer guidance about the use of some medications is necessary. EVIDENCE: Personal support plans are in place and describe in detail how individuals’ needs should be met in this area. Most staff offered discreet assistance ensuring that individual’ privacy and dignity is respected. It was noted that staff support people to get ready for bed quite early; a member of staff was observed to tell one of the people living at the home that it was time for a shower and to get ready for bed at 7.30pm. The temporary manager reported that this individual would then re-dress several times before going to bed. It is recommended that a more flexible approach be explored so that individuals can be supported at a time that suits them, encouraging control over their lives and independence. Colne House DS0000062797.V333383.R01.S.doc Version 5.2 Page 16 There was evidence in records that people are supported to attend a range of health care appointments and that staff generally monitor peoples’ health. However, records have not been kept of injuries sustained through selfinjurious behaviour, although the temporary manager has introduced this since she came to the home on 7th May 2007. The temporary manager demonstrated a good understanding and awareness of the importance of monitoring self-injurious behaviour, and the need to access medical attention when necessary. A survey completed by a local doctor who treats people living at the home indicated satisfaction with the overall care provided to people living at the home including a comment “No problem with the care of our patients. The current staff seem very competent to deal with the needs of their residents”. Medication was checked and found to tally with records kept. Medication is stored securely, and a controlled drugs book and more secure storage for controlled drugs have been arranged since the temporary manager came to the home. It was noted that “prn” (meaning to be taken as required) medication guidelines were in place. There was insufficient information to assist staff in making a judgement about when this medication should be administered. For example the guidelines for one individual stated that the medication should be given when the person was upset or in extreme case of anxiety. There was no further explanation about how ‘upset’ or ‘extreme case of anxiety’ might be presented by the person, and insufficient guidance about when additional doses could be given. It was unclear from the records examined what the rationale was when the medication had been administered, and there was no record of whether or not it had been effective. This was discussed with the temporary manager at the time of the visit who agreed to review the prn protocols. Colne House DS0000062797.V333383.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 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. Clear complaints procedures are in place, however people living at Colne House are not adequately protected form harm by the homes protection procedures or practice. EVIDENCE: A complaints procedure is in place, and this is also available in symbol format and was found in the individuals files that were examined. The pre-inspection questionnaire indicates that no complaints have been received by the home since the last inspection. However, in the surveys completed as part of the key inspection, some respondents indicated that they did not know how to make a complaint. The provider needs to ensure that people living at the home are reminded of the complaints procedure and that their relatives or advocates are also given information about how to make a complaint. It was noted in the records of residents’ meetings that were examined that people living at the home have been reminded about how to complain, however this should be revisited. A policy on abuse is available in the home. This needs to be updated to ensure it is in line with Kirklees MC procedures. Clear systems should then be put into place to ensure that all staff are familiar with the revised procedures. It was noted in records examined that a number of incidents have occurred where people living in the home have been hurt by another person living at the home. There was no evidence to indicate that necessary steps had been taken Colne House DS0000062797.V333383.R01.S.doc Version 5.2 Page 18 to protect individuals and the appropriate people had not been notified under adult protection procedures. A letter of concern was sent to the provider on 18th May 2007 requiring that urgent steps be taken to address this matter. The requirements included in the letter referred to are included as part of this report. It was concerning to find that appropriate measures have not been agreed to protect an individual when displaying self-injurious behaviours. A requirement has been made of the provider to ensure that appropriate behavioural management strategies be developed so that staff are clear about how best to protect this person. Staff training records show that a number of staff have not received up to date training in adult protection and a requirement has been made in respect of this. Colne House DS0000062797.V333383.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27,30 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. Colne House is a spacious, clean and comfortable home but bathroom facilities are in need of modernising. EVIDENCE: A tour of the premises was conducted including all communal areas and four bedrooms. The home was clean, comfortable and free from unpleasant odours. Since the last inspection, the ground floor bedroom has been vacated and is used as a quiet lounge, although there was little furniture in there. The acting manager explained that furniture had been ordered for this room. A stair lift has been installed to support those people with mobility difficulties to access the first floor. The ground floor flat that used to be occupied by the previous owner of the home, has been refurnished and decorated and is now used by a person living at the home. This offers a single bedroom, bathroom and sitting room. The relatives of the individual commented in the survey “We Colne House DS0000062797.V333383.R01.S.doc Version 5.2 Page 20 have never seen her as happy and content”. The provider had informed the CSCI over a year ago of its plans to modernise the building and provide single occupancy bedrooms. There has been no progress with this, and the Bridgewood Trust has not as yet informed the CSCI of the proposed timescales. There are currently two shared bedrooms at the home. One provides a partition for privacy, although the second double room has no privacy screens. It was noted in the Bridgewood Trust’s monthly management visit reports that are provided to the commission regularly, that this had been identified as a matter for action. There was no evidence to show that this had been addressed. It was reported by staff that one of the people sharing a bedroom has a tendency to disturb their roommate at night. Reference was made to this in the care plan, however the instruction to staff was “make sure I’m in bed as sometimes I mess around and disturb others”. It is recommended that the provider explores compatibility issues and whether a more suitable arrangement could be made that meets both people’s needs who are sharing a bedroom. Bathroom facilities need modernising and improving. There is a shower room on the first floor that includes a toilet and wash hand basin and a separate toilet, however there is no wash hand basin. On the ground floor there is a bathroom off the quiet lounge that is regularly used by one of the people living at the home, and a separate toilet with wash hand basin. The first floor bathroom needs attention, as the grouting, seal and shower curtain were stained. The manager reported that staff are now monitoring water temperatures on a regular basis, and a staff member confirmed this. It is the provider’s intention to upgrade bathroom and toilet facilities as part of the refurbishment of the home. Adequate laundry facilities are available in the basement including commercial washing machine with sluicing facilities and a tumble drier. Both people living at the home who completed a survey as part of the key inspection indicated that the home is always clean and fresh. Colne House DS0000062797.V333383.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 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. People who live at Colne House are supported by a generally skilled staff team. The recruitment procedures are not as thorough as they need to be to ensure that all people living at the home are protected. EVIDENCE: Staff presented as approachable and positive with people living at the home. People living at Colne House appeared to be comfortable in the company of the staff. Both people living at the home who completed surveys indicated that the staff always treat them well and this is positive. Through observation of care practice, staff demonstrated that they had the skills and qualities to meet most of the peoples needs living at the home. However, a number of entries in individuals’ records gave cause for concern in terms of how staff are managing challenging behaviour. There is insufficient guidance for staff in this area and further training is required. This matter was addressed in the letter sent to the provider following the inspection visit. All relatives that completed surveys said that they felt that staff had the right skills and experience to look after the people living at Colne House. Comments include, “ we have, on visits always Colne House DS0000062797.V333383.R01.S.doc Version 5.2 Page 22 found the staff most friendly with a smile and a welcome chat giving us the impression they are most caring”, “They understand *** and help her with things that she might find difficult to do by herself” Information provided to the commission by the Bridgewood Trust prior to this inspection indicates that of eleven care staff working at the home, five have achieved an NVQ level two or above in care. It is recommended that the remaining staff continue working towards achieving this qualification. New staff complete the Learning Disability Award Framework induction and foundation training and evidence of this was seen in staff training records submitted to the commission prior to the inspection. The Bridgewood Trust is in the process of recruiting a training officer as this post has become vacant since the last inspection. Staff training records indicate that most staff have received regular relevant training, and there was evidence to suggest that updates had been booked for some staff. A number of staff however have not received up to date training in adult protection or the management of challenging behaviour. This has been referred to earlier in this report. Staff recruitment records were examined. All files examined contained evidence that pre-employment checks had been carried out as required. However it was noted that although the provider had sent for Criminal Records Bureau checks, there was no record or evidence that any discussion or risk assessment had taken place where staff had convictions. This was raised with the provider in the letter of 18th May, and the Bridgewood Trust have since notified the commission that steps have been taken to address this. Staff spoken to confirmed that they attended a formal interview and were then invited to visit the home to meet people living there. There was evidence that people living at the home were asked their opinions of potential new staff and that this feedback was used as part of the selection process. This is good practice. Colne House DS0000062797.V333383.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 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. Colne House has not been well managed since the last inspection and peoples’ health and safety is not adequately protected. Although good quality assurance systems are in place, improvements in monthly provider visits need to be made so that the quality of care provided is monitored more closely. EVIDENCE: Since the last inspection, the acting manager has left the home and at the time of the visit a registered manager from another Bridgewood Trust home was overseeing the management of Colne House. The chief executive has informed the commission that the recruitment of a replacement manager is well underway and it is hoped that a suitable manager will be appointed soon. Through examination of a range of records and discussion with staff and the Colne House DS0000062797.V333383.R01.S.doc Version 5.2 Page 24 acting manager prior to her leaving, there is evidence that the home has not been well managed since the last inspection visit. A number of breaches in regulations have been identified at this inspection visit, and it is clear from the evidence in records that the manager had not fulfilled her responsibility in protecting all people living at the home. However, the temporary acting manager now in place at Colne House is an experienced manager who demonstrated her competence throughout the inspection. The commission is confident that the temporary acting manager has the skills to prioritise areas that require urgent attention and action. 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. Records of residents’ meetings were examined and it was noted that standard agenda items are: rights and choices, support, staffing, organisation and ‘any other business’. Provider visits are conducted monthly as required. Since the last inspection, the residential services manager has left the organisation and therefore another senior member of staff from the organisation has conducted the most recent visits. It is most concerning that the areas identified at this inspection that require urgent attention and improvement have not been picked up during these visits, despite there being evidence in the monthly providers report that the same individual’s records have been reviewed. The provider needs to explore this further to ensure that where there is poor practice, or improvements are necessary, this is identified and appropriate action taken. It was also noted that there is very little evidence to suggest that staff or people using the service have been consulted as part of the monthly providers visit and this must be addressed. Information provided by the Bridgewood Trust prior to this inspection indicates that regular safety checks and maintenance of equipment is carried out as required. Fire records were examined and there was evidence that fire safety checks are being conducted as required. A member of staff and the acting manager confirmed that since the last inspection, staff are checking hot water temperatures regularly to ensure that hot water is delivered close to fortythree degrees centigrade. For the protection of people living at the home and staff, risk assessments, individual care plans, behavioural management plans and agreed physical intervention strategies must be developed and maintained to ensure that all staff are delivering care as agreed. In order to ensure safe working practice, all staff must receive training in physical intervention and adult protection and adult protection matters must be reported appropriately. This has been discussed under standard 23. Colne House DS0000062797.V333383.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 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 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 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 2 1 X 1 X 2 X X 1 x Colne House DS0000062797.V333383.R01.S.doc Version 5.2 Page 26 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 Regulation 13(6), 15 Requirement Timescale for action 23/05/07 2. YA6 YA23 YA42 13(7)(8), 15 3. YA9 13(4) 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 unmet. 23/05/07 In order to protect people living at the home, where it is necessary to use physical intervention, this must be agreed as part of the care plan (and should be in line with Department of Health guidance), only used in exceptional circumstances and a record of the circumstances including the nature of the physical intervention must be kept. In order to protect individuals 23/05/07 from harm, unnecessary risks to the health or safety of people living at the home must be clearly identified and so far as possible eliminated. 31/10/05, 28/02/06, 31/07/06 unmet. DS0000062797.V333383.R01.S.doc Version 5.2 Colne House Page 27 4. YA20 13(2) 5. YA23 YA42 13(6),37 6. YA32 18(1)c 7. YA23 YA32 13(6), 18(1)c Clear guidance must be in place for the safe administration of prn (as required) medication and accurate records must be kept so that individuals’ health and wellbeing is protected. In order to ensure the protection of all the people living at the home, multi agency adult protection procedures must be adhered to in the event of individuals being harmed by other people living at the home. This must include notifying CSCI. In order to protect people living at the home and staff working at the home, all staff required to work with people who present challenging behaviour and expected to physically intervene with individuals must be provided with the appropriate training. In order to protect people living at the home all staff working at the home must receiving appropriate training in the protection of vulnerable adults. 23/05/07 17/05/07 30/06/07 15/07/07 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 YA24 Good Practice Recommendations In order to protect the privacy of those people in shared rooms, privacy screens should be provided. 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. The provider should provide an action plan indicating timescales for the proposed improvements to bathroom DS0000062797.V333383.R01.S.doc Version 5.2 Page 28 2. YA24 YA27 Colne House facilities. 3. YA32 Staff should continue working towards achieving NVQ level 2 or above. 50 of care staff should be qualified to NVQ level 2. Colne House DS0000062797.V333383.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.V333383.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. Re-publishing this information is in breach of the terms of use of that website. 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