Inspection on 16/01/07 for Condover College

This inspection was carried out on 16th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Condover College 14/02/06

Condover College 14/09/05

Condover College 03/03/05

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 Condover College Condover House Condover Shropshire SY5 7AA Lead Inspector Deborah Sharman Key Unannounced Inspection 16th January 2007 09:30 Condover College DS0000061651.V316078.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 Condover College DS0000061651.V316078.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. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Condover College Address Condover House Condover Shropshire SY5 7AA 01743 872250 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) Stephen McGill2@btinternet.com Condover College Vicki Pryce Care Home 21 Category(ies) of Learning disability (21) registration, with number of places Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may accommodate a total of 21 persons, who have learning, sensory and physical disabilities. Rooms 6 and 9 can only be used until 01.04.2007. Date of last inspection 14 February 2006 Brief Description of the Service: Condover College is a Care Home, registered with the Commission for Social Care Inspection to provide accommodation, personal care and education for up to nineteen young adults with Profound Learning Disabilities and Visual Impairment. The home is temporarily registered to provide care for up to 21 persons. This temporary arrangement is due to end at the end of March 2007. Service users are aged 18 - 24 years and are offered a transition between education and adult life. Condover College Ltd operates the home. Ms Vikki Pryce, the current manager, is responsible for the homes day-to-day management. The College is located in the village of Condover some three miles from Shrewsbury town. The main building is a three-storey house standing in its own spacious grounds. Three dormer bungalows situated in close proximity and accessed through a walkway from the main garden complement the main house. The Home seeks to provide a positive homely environment for service users affording the appropriate levels of support required to meet their needs and aspirations. The weekly fee ranges from £880.00 to £2000.00 Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection meaning that no one associated with the home had prior notification and was unable to prepare. The inspection was also a key inspection meaning that all key Standards as defined by the Commission for Social Care Inspection was inspected. One Inspector carried out the inspection over an 8.5-hour day beginning at 9.30am. Both the Chief Executive and Registered Manager supported the process of inspection throughout the day. Evidence to support the judgements made about the home’s performance was collated in a number of ways. Methods included discussion with the Chief Executive and Manager, interviewing a member of staff and briefer discussions with other staff. Evidence was also collated by touring the premises during which the Inspector was introduced to and briefly spoke with a number of service users. Service users by virtue of their disabilities were not able to verbally tell the Inspector what they think of the service provided to them by Condover College. However, the Inspector was able to observe their preparations to go out for the day, their demeanour and their interaction with staff and was able to observe one service user being supported to eat. The Inspector has also been able to formulate a judgement about satisfaction with care levels through written feedback provided to the Commission for Social Care Inspection prior to the inspection from all service users (supported by staff), from fourteen relatives and eleven independent professionals who have contact with the home. The Inspector also assessed in detail the care provided to one service user. This service user was chosen as s/he has been recently admitted to the home and has needs which would help the Inspector to judge how effectively the home responds to cultural diversity. Documentation for another service user was sampled to verify some aspects of care that required clarification. Information available to the Inspector from previous inspections, the Fire Service and the home itself together with information known to CSCI about incidents which have happened at the home since the last inspection all guided the focus for this inspection. The home is temporarily registered to provide care and accommodation for up to 21 service users but this is due to revert back to 19 at the end of March 2007. At this inspection the Provider indicated that they would be applying to register to provide care and accommodation for 20 service users permanently. What the service does well: Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 6 Condover College meets service users needs very well. Strong systems ensure this. For example robust admission processes ensure service users are assessed rigorously before a decision is made to offer them a place and care planning contains an excellent amount of detail all of which is known to staff who carry out the care. Condover College is aware of service users cultural needs and works hard to ensure that these are met. The home is a hive of activity with a range of activities and outings being available. Whilst assessing the care of one service user the Inspector could see from records that in the space of one week the service user had taken part in a range of in house and community activities, all of which directly matched the service users known interests. Condover College has high expectations for its service users. Their goals and aspirations are known and there are systems in place to help them to be realised. Staff present as motivated, welcoming and caring. Relatives have provided CSCI with some exceptional feedback, a common theme being praise for staff. Relatives have told CSCI the following: ‘My daughter is extremely happy at Condover and counts it as her home. She talks none stop about staff and students alike and has made some excellent friends. Their care and support to myself have been consistently good.’ ‘We are very pleased with everything and are very impressed with how staff keep us informed of events / Doctor appointments and pleasure activities. ‘Excellent care provided at all times. The staff are 100 friendly, welcoming, caring etc. Wouldn’t send my son anywhere else. Well done to all concerned!!’ ‘ The staff are lovely – young and energetic and also well trained. They have sought out new training, new knowledge, and agreed new practice to meet our son’s unique needs. They listen to what we say. They find time to talk to us about our needs and our family as well as X’s needs. Condover is exceptionally good. Our son is happy, healthy, busy and secure – he knows his carers enjoy his company. We visited nine other establishments and had prospectuses from dozens – Condover is easily the best.’ ‘ My experience so far is that the staff are extremely friendly, committed to their residents and their well-being. When visiting my son we are welcomed with open arms, nothing seems too much trouble for them.’ Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 7 Professionals including Social Workers, Doctors and other health professionals wrote the following about Condover College: ‘I found the staff to be supportive and friendly. They also appeared to care well for X’ ‘Staff are always helpful on the phone and reviews for the individual are generally positive.’ ‘Condover College Ltd provides in my opinion excellent and individually tailored support to its residents.’ ‘Out of all the residential establishments that I visit there is no doubt Condover College provides the highest level of quality of care that I have seen. They continue to try to improve in all aspects of care and it is a pleasure to be involved in the team’. ‘Yes staff demonstrate a clear understanding of service users needs’ I… was impressed by the level of care and staff commitment. I have a very good level of communication with the college and am invited for all reviews and updated regularly on my clients progress’ What has improved since the last inspection? Requirements issued at the last inspection to ensure improvement have been met. Soap and paper towels are now available in bathrooms to better promote infection control and systems to minimise the risk of scalding from hot water have been improved. It was concerning therefore to all that at the weekend prior to the inspection a service user was scalded whilst being supported to use the shower. Investigations to date have drawn the conclusion that there was an unusual shower malfunction but technical reports in respect of the shower are awaited. A previous requirement had been made by CSCI to ensure that an appropriate door closure is fitted that is linked to the fire alarm system so as to close effectively in the case of an emergency. The fire service has confirmed that current door closures that are not wired into the system are acceptable. At the time of inspection the provider believed that more of the existing battery door closures were required but has since confirmed this not to be the case. The requirement has therefore been deleted. Some rooms have benefited from decorating and steps have been taken to ensure that facilities meet the needs of service users. For example a shower tray has been removed and replaced with an alternative design to ensure that a shower is better accessible for a service user with a physical disability. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 8 What they could do better: Since the last inspection there have been seven medication errors reported to the Commission for Social Care Inspection (CSCI). Assessment of medication has found some areas where practice should improve. Since this inspection and prior to writing this report, a detailed and robust action plan to assess and improve medication practice to reduce the risk of error has been submitted by the Provider to the Commission for Social Care Inspection. Shortly before this inspection, in December 2006 the Fire service inspected the premises and made some recommendations, which have been responded to. However, the Provider is choosing not to act upon some good will advice provided by the Fire Service in part due to cost but also due to concerns about the appropriateness of the recommendation for a small domestic scale dormer bungalow. The Fire Service considers current arrangements to be complying with the law. It was difficult to assess training due to a lack of documentation that provides an analysis of training undertaken for staff both as a team and as individuals. The Provider accepts that training systems need to be improved although staff benefit from the provision of training. Prior to the inspection a relative informed the Commission for Social care Inspection that ‘we sometimes experience a lack of coordination between the different shifts and information is not always readily available when we telephone’. Discussion with a staff member confirmed this. Although following feedback from staff recently, some steps have been taken to improve communication, staff, the Manager and the Chief Executive accepted the need to improve the handover system to promote better communication between staff. One complaint has been made (about the provision of personal care) since the last inspection. This received a timely response and appears to have been resolved to everybody’s satisfaction. It was unclear from records and from the Provider and Managers recollection what had been the outcome of the complaint investigation and the Provider agreed that ‘closure’ of the complaint could have been better. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 9 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. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 10 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 Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is excellent. Admissions procedures are thorough and are adhered to. A full range of staff and other professionals contribute to the pre admission assessment. Service users can be reassured that their needs will be very well assessed and they will only be admitted to the home if Managers are confident that their needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is an excellent admissions policy and procedure in place that guides staff through the stages to admission from the first enquiry or referral. Admission was assessed for the service user who was case tracked and it was evident that the stages had been adhered to in practice. Several staff carried out a very detailed assessment of the service user using observation and discussion at the service user’s home and in the service users educational centre. A range of reports from other professionals involved had also been obtained and informed the homes own assessment. The service user had also taken up the offer of an overnight trial visit to the home. The service user was formally offered a place once the decision had been made that Condover College could meet her assessed needs and she is settling well. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 12 Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 13 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is excellent. Care plan and risk management systems with one exception, provide excellent guidance to staff as to how to meet service users needs. There is also clear guidance re how service users make their own choices and excellent evidence that this advice is adhered to by staff. Outcomes for service users are excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans contain excellent detail and provide staff with a clear picture of the service users routines, needs, preferences and goals. Particularly useful is the attention to foibles that are specific only to that service user and if known and acted upon make a difference to the service users emotional well-being and contentment. Discussion with staff showed for example that in keeping with the care plan that they are aware of how to help the service user settle to sleep at night in a manner consistent with her family’s approach. There is also good attention to cultural needs and again staff understand what is required of them in this respect. Feedback to CSCI from independent professionals who have contact with the home shows they are satisfied their advice is Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 14 incorporated into care planning. This was evidenced for the service user case tracked whose care plan had been amended following advice from a dentist. There is good evidence that the service user’s transition to Condover College has been reviewed well in consultation with multidisciplinary agencies and records provide good evidence of care to date and plans for the future. The Inspector was able to see that targets set at review meetings had been acted upon. Care plans include excellent guidance as to how the service user case tracked can make choices. Again staff were very knowledgeable about this aspect of her care. Records too provide excellent evidence of how the service user has been supported to make choices and how these have been respected. Individual risk assessments are in place to minimise a range of hazards identified for the service user. The only significant omission in care planning is medication. Currently the only record of prescribed medications is on the Medication Administration Record which is not always up to date as prescriptions are changed. An up to date record of administered medications in the care plan which is amended to account for changes in medical direction would provide better clarity for staff and would help to reduce the risk of confusion and possible error. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is excellent. Opportunities are fully available for service users to develop social, communication, emotional, educational, independent skills and to maintain links with their family whilst also being active participants in their local community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Educational and leisure activities are well planned and opportunities are very frequent. A range of activities were taking place on the day of inspection – lunch out at Cosford Air Museum, an Indian meal out in the evening for a service user’s birthday, drama, exercises and cooking etc. In the space of one week records show the service user case tracked had been out 6 times and had taken part in additional activity within the home – all which accord with her assessed interests and preferences. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 16 The Inspector was able to observe a group’s preparation for going out to Cosford Air museum. A service user was being given time to adapt to the news of the planned outing to minimise her anxieties which are known to arise prior to any visit out. She returned positively having enjoyed the day. Goals are set for service users. This accords with relative’s comments that staff strive high and have aspirations for service users. There is excellent evidence of frequent contact between each service user and their family and staff and service users families. It is positive to see evidence of contact instigated by phone by both the family and staff and this matches written comments from relatives who say they appreciate the interest, support and concern of staff for the whole family. The Inspector was also able to see copies of letters service users had been supported to send to their family. Positive links with the local community are being established and holidays for service users are annual and are funded by the College. Food stocks were inspected in all of the houses. Food stocks are plentiful and arrangements are made to provide specialist food to meet cultural requirements. At lunchtime the Inspector observed a service user receiving assistance to eat. This was provided on a one to one basis and at an appropriate manner and pace. The evening meal was also observed in the main house and was well presented, appetising, healthy and substantial. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good overall. Outcomes are good for personal care and health. Several errors in medication have happened since the last inspection and this inspection has highlighted some areas for improvement to ensure the promotion of both service users health and safety. A robust action plan to ensure improvement has been developed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The personal care needs of service users are well known, well documented and this aspect of care is provided well. All service users are clean and well groomed according to their individual taste and preferences. Service users’ moving and handling needs are assessed and there are suitable aids and adaptations available to support physical need when bathing and showering. Adaptations have been recently made to facilities to meet need e.g. a shower cubicle has recently been replaced to make it more accessible for a service user. Hoists and a stair lift are available. In one house there was a hoist each for 4 service users. Shower chairs are available too. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 18 At the pre admission stage a service users potential to make progress with independent toileting was recognised. This was discussed further at the first review after admission and goals set have been acted upon and the service user is making progress. This is clearly evidenced. Service users health care needs are also well met by the home. There are few accidents to service users and systems are in place to monitor well being. There is good evidence that routine health screening is provided and that changes in service users health are identified and acted upon. There is also good evidence from records and from medical professionals feedback that their advice is incorporated into planning and is acted upon. The home has an excellent system for recording medical appointments to aid communication between staff for the benefit of service users health. It is important too that any telephone advice given by health professionals is recorded to demonstrate compliance with duty of care and to ensure continuity of care for the benefit of the service user. Time constraints meant that medication was not assessed in detail and was only assessed for the service user case tracked. There have been seven errors in medication practice since the last inspection involving mainly the nonadministration of prescribed medications and on one occasion giving one service user the wrong medication. Fortunately on these occasions service users suffered no ill effect, however there is the potential for risk of harm. Some areas for improvement in medication management were identified at this inspection. Therefore as the home manages some controlled drugs, the Manager has developed a robust improvement plan. This includes a plan to commission an assessment of practice by a qualified pharmacist and the intention to implement any arising recommendations. There is evidence that service users medication is reviewed regularly and ordering, receipt and storage of medications appears to be acceptable. Only trained staff administer medication and the Manager said that an ongoing competency to administer system is assessed. This is positive practice and should seek to minimise errors occurring. Changes to prescribing directions were difficult to account for. Also for the service user case tracked there was some evidence of staff amending prescribing directions without medical authorisation for a prescribed cream for practical reasons. The result of this being that the service user is only given up to half of the prescribed external treatment therefore reducing its efficiency and the health benefit to the service user. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 19 Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 20 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. Complaints are responded to in a timely manner and systems are in place to safe guard service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection Condover College has received one complaint about the management of personal care leading to soreness of skin areas. There is evidence that the complaint was taken seriously and a recorded meeting involving representatives from the home, the complainant and the social worker was held swiftly. The Manager said that the complaint was resolved to the satisfaction of all parties but there is no clear-recorded outcome. A summary letter indicating whether the complaint had been upheld had not been sent to the complainant and the outcome is not recorded in a complaint log. Discussion at inspection has shown that as a result of the passage of time no one could remember whether the outcome had shown Condover to be ‘culpable’ or not and it was accepted that the ‘closure’ of the complaint could have been better. An adult protection and whistle blowing procedure is in place and is understood by staff. Discussion with a staff member showed her to have a good understanding of her role in the event of concern about the safety or protection of a vulnerable service user. The home has previous experience of the Adult Protection reporting and response system. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 21 Financial systems for the service user case tracked are appropriate and safe and a detailed policy on the management of service users money guides staff. However since the last inspection an incident has been reported to CSCI where managers discovered that a staff member had not adhered to the procedure and money, which was immediately returned, was missing at the point of audit. The Managers assured the Inspector that Social Services and the Police had been informed in accordance with procedure but that these agencies were satisfied for the matter to be dealt with internally. The Inspector saw the appropriate documentation including those connected with the subsequent disciplinary investigation and action. Control measures are in place to ensure that the incident is not repeated. Staff recruitment practice at Condover College provides additional safeguards for service users. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. Service users live in a clean and homely environment that has aids and adaptations to meet service users physical needs. The premises are subject to ongoing decoration, improvement and adjustment and changes required to meet individual service users needs are identified by the provider and are prioritised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are accommodated in small groups in the main house and in three other houses, which although they have independent addresses are all accessible from the grounds of the main house. Accommodation is warm, domestic in style and adapted to meet service users needs. Some redecoration has taken place since the last inspection. Service users bedrooms are individualised and very personalised depending on individual taste and preference. The Provider is aware of areas that require updating or refitting and plans to address this in due course. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 23 All areas of all houses are clean and smell fresh. A contractor collects clinical waste weekly and laundry including soiled linen is also contracted out three times per week. Safeguards are in place to prevent cross infection whilst the laundry is awaiting collection. The Managers are very satisfied with the laundry service provided to the home explaining that all service users personal laundry is returned to them separately and that the arrangement enables the home to engage with the local community. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is good. Staff are recruited well ensuring the safety of service users and present as creative, motivated and competent with a good understanding of service user need. There was evidence that supervision frequency for one staff member has exceeded the national minimum standard This judgement has been made using available evidence including a visit to this service. EVIDENCE: Rigorous checks are undertaken when recruiting staff for the protection of service users and practice fully complies with the legislation. It was difficult to assess training as an analysis of training is not available for the team and Managers accepted the need to improve this. However, there are no known concerns about staff competence and there is good evidence that at point of selection applicants’ prior training is sought, copied and retained. In addition new staff are provided with an appropriate induction. A new staff member had done fire training, infection control training and moving and handling training at Condover early in their employment with the organisation. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 25 The roster system manages the deployment of staff well and current good outcomes for service users combined with satisfaction of staff and most carers with staffing levels indicates no current concern about the numbers of staff available to meet service user needs. Aspects of staffing arrangements have improved. Staff are now given additional time off rota for reading and record keeping and are allocated additional time to provide one to one key working time with service users. However the need to review and improve handover processes was agreed. A relative commented that although they are delighted with the service provided generally, ‘we sometimes experience a lack of coordination between the different shifts and information is not always readily available when we telephone’. A staff member said she had also identified the need to improve handover, particularly in the morning as ‘I come in 7.30 or 8am and have missed handover as it is at 7am –7.15. I would like more time at handover or a handover sheet to update me. I don’t know what I need to do when I come on.’ The staff member commented too that other suggestions for improving communication had been acted upon and were now working well. Documentation to evidence supervision for one staff member was not available as it was inaccessible in the absence of her supervisor. Assessment of supervision records for a second staff member, a House Leader shows the National Minimum Standard to have been exceeded in terms of the frequency of supervision provided. A staff member told the Inspector ‘I feel we have some very good staff here – they are very caring and approachable and we work well as a team’. Comments from relatives and professionals quoted at the beginning of this report demonstrate a high level of satisfaction with Condover College staff. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. There are good management systems in place to enable the home to meet its stated purpose, aims and objectives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff spoke highly of the management approach, which is defined by managers as based upon respect and trust. The Manager is experienced, registered and qualified and has updated her knowledge and skills by attending training and relevant conferences. Staff meetings are held weekly, are well attended and are fully documented. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 27 Managers and staff were cooperative and positive during the inspection process and responded positively to suggestions for improvement including the need to review systems to improve medication practice as a priority. The Manager has submitted a detailed medication improvement plan to CSCI. There is evidence that the home has a quality assurance system, which enables it to assess its own performance. The Inspector was provided with a copy of a self-assessment report that is presented annually to the home’s board. This includes an analysis of customer feedback and the next is due to be completed by March 2007. The Chief Executive said that they ware planning to explore the use of other professionally recognised quality assurance systems. Service Maintenance documentation that was sampled is acceptable. There is evidence of fire drills, in house fire system checks and external contractor fire system services. During a tour of the premises a service user told the Inspector that she had been involved in a fire drill the day before to ensure safety. There is an ongoing programme of fire training with 6 sessions booked for 2007. The fire risk assessment has been updated following a Fire service visit and advice in December 2006. The Inspector has had telephone contact with the Fire Inspection Officer since the inspection who indicated that Condover College are complying with current fire regulations and given the risk are judged to be sufficiently safe by the fire service. The Fire service however is disappointed that Managers are choosing not to implement the Fire Services good will advice. As improvements have been made to procedures to minimise the risk of scalding from hot water, Managers and staff are distressed that a scalding incident occurred prior to this inspection in January 2007. Action was taken to safeguard other service users in the aftermath and currently the Inspector is lead to believe that two of the shower’s inbuilt safety features both failed. The Inspector has written to the home to ensure that the safety of all other showers is to be checked and has verbally received this assurance. A technical report in respect of the shower where the scald occurred is awaited. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 28 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 4 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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 3 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 X X 3 X Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 29 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 YA20 Regulation 13(2) Requirement The Registered person must make arrangements for the safe administration of medicines by ensuring that: • An up to date record is maintained of current medication for each service user. Amendments to medical prescribing directions are not changed without medical authorisation. Any changes to medical direction for the administration of medicines including creams can be accounted for. Timescale for action 28/02/07 • • New requirement arising from this inspection January 2007. 2 YA22 22 The registered person must within a minimum of 28 days, inform the person who made the complaint of the action (if any) that is to be taken. New requirement arising from this 28/02/07 Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 30 inspection January 2007. 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 YA35 Good Practice Recommendations A training needs assessment for the staff team as a whole should be carried out based upon the home’s service aims, service user needs and individual plans. Recommendation arising from this inspection January 2007. 2 YA36 The Registered Manager should review current handover arrangements to ensure that staff are provided with the information they need to carry out their jobs. Recommendation arising from this inspection January 2007. 3 YA42 The Registered Provider should consider implementing the good will advice provided by the Fire Service at inspection of the premises on 29 December 2006. Recommendation arising from this inspection January 2007. Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Condover College DS0000061651.V316078.R01.S.doc Version 5.2 Page 32 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!