Inspection on 22/08/06 for Cottingham Road

This inspection was carried out on 22nd August 2006.

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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cottingham Road 30/08/07

Cottingham Road 23/05/05

Cottingham Road 31/01/05

Cottingham Road 14/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

St Marys Nursing Home

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

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

CARE HOME ADULTS 18-65 Cottingham Road 399 Cottingham Road Corby Northants NN18 0TW Lead Inspector Mrs Kathy Jones Unannounced Inspection 22nd August 2006 02:00p DS0000012753.V306579.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 DS0000012753.V306579.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. DS0000012753.V306579.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cottingham Road Address 399 Cottingham Road Corby Northants NN18 0TW 01536 401888 01536 406388 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) Royal Mencap Society Vacant Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places DS0000012753.V306579.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd May 2005 Brief Description of the Service: Cottingham Road is a care home providing personal care and accommodation for four younger adults with learning and physical disabilities. The Premises are owned by the health authority and are managed by New Era a housing association. Each resident has a tenancy agreement with New Era. The national charity Royal Mencap Society provides the care service. Cottingham Road is a bungalow, which is located on the outskirts of the town of Corby. There is a large mature garden area to the side and rear of the building, which is accessible to residents’. All of the bedrooms are single, there are no en-suite facilities however there are washbasins in each bedroom. The communal areas, have limited space, and there is insufficient space in the lounge for all of the service users to sit together, given that additional equipment, such as wheelchairs and adapted seating is required. There is one communal bathroom Information about current fees was provided in the pre-inspection questionnaire received on 10 July 2006. The fee per resident per week is currently £352.39. In addition to the fees, local authorities provide a grant to Mencap for provision of the services in the county. Residents pay an additional £62.35 per week from their benefits. The fees include personal care, staff support, accommodation, meals, laundry and a contribution towards a holiday. A list of additional costs and who is responsible for payment is available from Cottingham Road. Items to be paid by the resident include activities, meals and drinks while out, hairdressing and travel for pleasure. DS0000012753.V306579.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. All standards identified as ‘key’ standards and highlighted through the report were inspected. The key standards are those considered by the Commission to have a particular impact on outcomes for people living in the home. Inspection of the standards was achieved through review of existing evidence, preinspection planning, an unannounced inspection visit to the home and drawing together all of the evidence gathered. The review of evidence and pre-inspection planning was carried out over the period of half a day and involved reviewing the reports of the last two inspections, the latest carried out in October. The service history was reviewed, which details all contact with the home including notifications of events reported by the home, any complaints and telephone calls. A preinspection questionnaire submitted by the registered manager was also reviewed. No completed questionnaires from relatives or health professionals had been received at the time of the inspection. All of the information gathered assisted with planning the particular areas to be inspected during the visit and has informed the findings in this report. The unannounced inspection visit covered the afternoon and evening of a weekday. The inspection was carried out by ‘case tracking’ which involves selecting a sample of people and tracking their care and experiences through review of their records, observation of interactions with care staff and care practices. None of the residents’ have any verbal communication therefore it has been necessary to form judgements about their experiences based on all other evidence including observations. The management of residents’ medication was reviewed and a file for a recently recruited staff member was reviewed to check the adequacy of the recruitment process. Discussion took place with the acting manager throughout the inspection and feedback given. The use of the term ‘residents’ has been used in the body of this report, rather than ‘service users’ as this is how they are referred to in the home. DS0000012753.V306579.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: While improvements have been made to care plans, because they are not being regularly reviewed and updated, information about care needs may be out of date. This has the potential for residents’ needs to be not fully met. Discussion with staff identified that efforts had been made to identify some leisure activities which individual residents’ may enjoy however opportunities to take these up appear to have been limited due to inadequate staffing levels. On the evening of inspection a resident was taken to a social club as there was sufficient staff on that evening however due to irregular attendance due to staffing levels staff had been unaware that the club was closed that evening. DS0000012753.V306579.R01.S.doc Version 5.2 Page 7 Practices in relation to mixing tablets with liquid medication need to be checked to ensure that this does not reduce the effectiveness of the medication. While residents interests appear to be generally well protected however a requirement has been made that the way in which mobility allowances have been managed in the past, is looked into and addressed to ensure residents’ interests are protected. Some improvements to the premises have and continue to be made however space is very limited particularly as most of the residents’ require a lot of equipment to assist with daily living and mobility. The fact that there is just one accessible bathroom also causes some difficulties in meeting residents’ needs. The staffing levels that the organisation assessed as necessary to meet residents needs have not been consistently maintained. It had been identified that three staff were required in the early morning and evening periods from Monday to Friday, on most occasions the number of staff on duty has been two. . The amount of management support in the home should be kept under careful review to ensure that it is sufficient to support staff and residents. 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. DS0000012753.V306579.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000012753.V306579.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. The admission process provides assurances that the needs of Residents entering the home can be met. EVIDENCE: The pre-inspection questionnaire identifies that there are no vacancies at Cottingham Road and there have been no new admissions for the last six years. The acting manager confirmed that Mencap have an assessment format which would be used to determine prospective residents’ needs and if they could be met within the home. The assessment process includes several opportunities for prospective residents to visit the home prior to moving in. The registered manager confirmed that since the last inspection the statement of purpose has been updated and now contains all of the information required by the Care Homes Regulations 2001. The statement of purpose is considered to be an important document in that it sets out the services and care, which the home provides to residents. The acting manager confirmed that she would forward a copy of the updated statement of purpose to the Commission for Social Care Inspection. DS0000012753.V306579.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. The lack of regular review and updating of care plans as needs change creates the risk of residents’ needs not being fully met. EVIDENCE: At the time of the last inspection in October 2006 progress was being made in developing and improving care planning systems and risk assessments to support and guide the care provided. Some aspects of the care plans were very good and provided new staff with clear information about residents’ and their needs. One care file contained a series of photographs demonstrating how the hoist should be used. Residents are very dependent on staff for all their needs; they have no verbal communication and are reliant on staff to accurately interpret their needs through non verbal communication. Some clear information was provided in one residents care plans about how they communicate through different sounds. DS0000012753.V306579.R01.S.doc Version 5.2 Page 11 Review of the care plans in place for one resident identified that the plans were not dated, signed by the person drawing them up and there was no evidence of the involvement of the resident and/or their representative. It is particularly important to ensure that care plans detail who has been involved and how any decisions that have been made on residents’ behalf have been arrived as the residents’ at Cottingham Road have no verbal communication. Discussion with the acting manager identified that the plans had probably been drawn up in November 2005 however there was no evidence of review or update of the plans. This was so with another residents’ care plan checked where some advice had been given from a health professional, which had not, been incorporated into the care plan. It was of concern that if the care plans are not being used as a working tool and kept up to date this could lead to residents’ needs not being appropriately or fully met. A new member of staff confirmed that they had been asked to read residents care plans in order to be aware of their individual needs which emphasises the importance of them accurately reflecting current needs. The inspector was informed that a more person centred approach to care planning is going to be introduced throughout the Mencap homes that will incorporate residents goals and aspirations which are not currently included within the plans. The acting manager has identified the end of December 2006 for the implementation of the new plans. The inspector would advise during this changeover to new plans that care should be taken to ensure that whatever type of care plan is in use that they are updated as needs change and that staff are clear about which care plan to follow to ensure residents’ care is not compromised. Given that due to residents dependency levels a lot of decisions are made on their behalf, plans should clearly evidence how any decisions have been arrive at and demonstrate that where possible attempts to involve the resident and their representative in the decision making have been made. DS0000012753.V306579.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. While staff appear to work hard to identify activities that provide residents with a fulfilling life, opportunities are limited by staff shortages. EVIDENCE: The needs of the current residents are such that they are unable to take part in paid employment however they are all involved in various activities and have opportunities to go on outings through a day centre. On the day of the inspection all of the residents’ had been out to day centre and were collected by a member of staff. Discussion with staff identified that efforts are made to assist residents’ in accessing community facilities and they had made enquiries about local activities, which would be accessible and suitable for the residents. Staff had found opportunities limited in the local area for people with the level of disabilities however discussion and records indicate that where possible opportunities are taken up. For example each resident is allocated some one DS0000012753.V306579.R01.S.doc Version 5.2 Page 13 to one time from a member of staff each week and the time is used to go shopping, out for lunch or for a walk. Records show that one resident had been to the theatre. Difficulties in maintaining staffing levels are a barrier in providing regular activities for residents. For example activities were detailed on the activity plan for one resident, which she had not started to attend due to insufficient staff. On the evening of inspection there were three members of staff on duty, which allowed a resident to go to a social club for people with a learning disability, however on arrival they found the club closed which they hadn’t been aware of due to irregular attendance. Residents have the opportunity to go away on holiday with staff support and have been to different locations. Staff advised that the destination is arrived at through discussion about individual needs, for example a resident with poor circulation went to Tenerife as it has been found they are more comfortable in the warmer weather. All residents are due to have an additional ‘holiday’ this year as they will stay at the Mencap holiday bungalow while some redecoration and refurbishment work takes place at Cottingham Road. Discussions with staff confirmed that every effort is made to support residents in maintaining family relationships. A relative telephoned during the inspection to check what kind of day it had been for a resident, staff confirmed that they provide daily information where necessary and always ensure they inform relatives of any changes. It is the practice within the home for staff to sit and eat meals with the residents. On the evening of inspection residents’ had a cooked meal consisting of breaded chicken, potatoes and cabbage, followed by stewed apple and custard. The apples came from the trees in the garden. Staff advised that they are starting to look more closely at the menus and individual residents’ nutritional requirements as some concerns have been identified about apparent recent weight gain in some residents. A sample check of residents weight records identified that these are not being monitored regularly however the acting manager advised that arrangements had been made for residents to be weighed at least monthly at the day centre where they suitable weighing machines. The inspector would advise that care should be taken to ensure that this information is used to inform care planning in relation to nutritional needs. DS0000012753.V306579.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. Healthcare advice, support and services appear to be accessed appropriately for residents, however more care needs to be taken to ensure that all information is properly documented to ensure that residents health needs can be properly monitored. EVIDENCE: Staff have developed a good understanding of residents’ and their personal support needs and were mindful of protecting their privacy and dignity. One resident had been assisted to relax by spending some time in her room using a foot spa with some music playing. Records show that health care services are accessed on behalf of residents’, however records did not always identify the results of any tests such as blood tests taken. Records are kept to monitor seizures and include information about the onset, the seizure and the recovery however a sample check against the daily notes and the seizure chart identified that these are not always completed which may mean that changing patterns are not easily identified. DS0000012753.V306579.R01.S.doc Version 5.2 Page 15 Records indicate that good support had been provided for a resident during a hospital admission. Arrangements had been made for staff from Cottingham Road to support the resident during the hospital stay to ensure there was someone familiar to them and with their needs. Residents’ are reliant on staff to administer medication. Practice in relation to the administration of medication was observed during the inspection and it was noted that tablets are given on a spoon with lactulose syrup. Staff advised that this helps residents to swallow the tablets. The inspector discussed this practice with the acting manager who was not aware of this practice. The acting manager confirmed that she would seek advice from the pharmacist to ensure that the effectiveness of medication is not reduced. Prior to administration two members of staff check medication. Stock levels of medication held are kept to a minimum and a staff member was observed checking the new medication received into the home. This enables any errors to be quickly identified and resolved to ensure that residents prescribed medication is always available. DS0000012753.V306579.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. Residents are generally well protected by caring staff however the way in which mobility allowances have been managed in the past needs to be looked into and addressed to ensure residents interests are protected. EVIDENCE: The Commission for Social Care Inspection have received no complaints about the service since the last inspection. The acting manager confirmed that no complaints have been received by the home. The inspector spoke to five members of staff during the inspection, three in individual discussions. No concerns were identified about the treatment or care of the residents. Due to the level of disability and limited communication residents were unable to express themselves. However the inspector observed that residents’ responded well to staff. Some staff have received training in protection of vulnerable adults procedures. A sample check of the management of resident’s finances identified that systems are in place to monitor monies spent on residents’ behalf with receipts kept to verify purchases. It was identified at the last inspection that some money for decorating items had been taken out of a fund for care payments and advice was given to arrange for an independent audit of residents monies to be carried out to ensure that they have all received their full entitlements. DS0000012753.V306579.R01.S.doc Version 5.2 Page 17 Review of a sample of the finance records identified that this remains an area that requires close monitoring as some records were either not fully completed or incorrectly completed particularly in relation to whether mileage should be charged to the home or the individual resident. The action plan submitted to the Commission for Social Care Inspection (CSCI) following the inspection confirmed that a full audit of all residents’ funds would be carried out. The inspector was informed that this had been carried out and some monies had been refunded. It was also confirmed that the ‘car account’ was no longer being used to deposit or withdraw funds. Although part of the problem relating to the management of residents monies appears to have been resolved it has also come to light that the arrangements and decisions made several years ago regarding setting up the residents car fund for the purchase of a car to transport residents’ may have financially disadvantaged some residents. Issues relating to ownership must also be resolved. There are no indicators to suggest that money has been deliberately misappropriated and the situation would appear to be very complex however it is of concern that several months later there appears to have been little or no progress in resolving the matter. DS0000012753.V306579.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 30 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. The premises do not fully meet the needs of the current residents. EVIDENCE: Cottingham Road is indistinguishable from any other family home and staff had planted hanging baskets and pots at the front of the house. Cottingham Road is a bungalow, which is located on the outskirts of the town of Corby. It has a large mature garden area to the side and rear of the building with trees and plants and some raised flower beds providing a pleasant area to sit when the weather is good. There is also space for car parking at the front of the home. The lack of adequate space to meet the needs of residents has been the subject of various requirements and recommendations since the establishment of the National Care Standards Commission the predecessor to The Commission for Social Care Inspection in April 2002. Previous requirements have also been made regarding the number of bathing facilities; the bathroom is required for all four residents and is also used by staff who carry out a sleep DS0000012753.V306579.R01.S.doc Version 5.2 Page 19 in shift. However Mencap have confirmed in an action plan that they are satisfied that the premises meet the needs of people living there and that this is validated by needs led assessments carried out by care managers working for the placing authority. Due to observations and discussions with staff about the practicalities of caring for residents’ on a day to day basis the inspector would advise that the adequacy of the premises in meeting residents’ needs without limiting their quality of life should be kept under careful review. For example the communal areas, have limited space, and there continues to be insufficient space in the lounge for all of the residents to sit together, given that additional equipment, such as wheelchairs and adapted seating is required. However the inspector was informed that difficulties with dining space are being addressed as part of some alterations at the end of September 2006. Currently when the dining table is extended to accommodate four residents and staff there is insufficient room to take someone in a wheelchair from one side of the table to the bathroom at the other side. Equally it is not possible to exit the office without someone moving from the table. Two residents’ remained in their wheelchairs during the meal and following the meal they were moved into the lounge in their wheelchairs while the table was taken down to make more space. Due to the limited space and difficulty bringing the hoist in from the garage staff advised that in order to transfer to the more comfortable lounge chair it was necessary to take the resident to her bedroom, use the ceiling hoist to transfer her to the bed and then to the lounge chair which had been wheeled into the bedroom. The resident was then wheeled back to the lounge in the chair. This inspection did not cover the early morning period however staff report that there continues to be a problem with only having one bathroom. For example it can take up to one hour to bathe one resident due to their individual needs, which obviously has an impact on other residents. All of the bedrooms are single, there are no en-suite facilities however there are washbasins in each bedroom. The toilet and bathroom facilities comprise one separate toilet, inaccessible to wheelchair users and a bathroom, which contains a toilet, shower and domestic bath and hoisting equipment. The bathroom was refurbished and re-tiled prior to the last inspection with equipment more suited to residents needs installed. Grab rails and additional equipment such as a shower chair to reduce the risk of a resident slipping have been provided since the last inspection. A moulded commode has also been obtained allowing a resident more dignity. The acting manager advised that some re-decoration and refurbishment is due to take place at the end of September 2006 while the residents are away at the Mencap holiday bungalow. This will include replacing fencing and laying tarmac on the area at the front of the home, which will include the pathway to DS0000012753.V306579.R01.S.doc Version 5.2 Page 20 the front of the home, which continues to be broken and uneven. Internally rooms are going to be re-decorated, the kitchen replaced and new flooring put in most areas. The acting manager advised that there were no imminent plans to address the shortfalls in space however various options are still being explored. The front door is not easily accessible to the three wheelchair users due to the raised lip at the bottom. Good standards of hygiene are maintained with all areas being clean and tidy with no unpleasant odours. DS0000012753.V306579.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. Arrangements for recruitment and training of staff are good, however staffing levels continue to be insufficient at times to meet residents’ needs. EVIDENCE: The pre-inspection questionnaire submitted identifies that 50 of the staff team have achieved a National Vocational Qualification. This qualification provides staff with a basic understanding of care practices. The acting manager advised that she was in the process of checking staff training to ensure that they had all received training considered to be necessary to meet the needs of residents. A new member of staff confirmed that a training programme is in place and that this included induction training. Ongoing concerns have been raised during inspections about the adequacy of the staffing levels in meeting residents’ needs at particular times of the day. An action plan submitted by Mencap following the inspection carried out in October 2006 stated that additional staff needs had been identified for key times. The key times referred to were 7.30am to 10.30am and 4.30 to 7.30pm Monday to Friday. A sample check of the rota and discussion with staff identified that these staffing levels have rarely been achieved. While it is DS0000012753.V306579.R01.S.doc Version 5.2 Page 22 acknowledged that attempts have been made to recruit staff it is not acceptable that there are insufficient staff to meet residents needs and action must be taken to address this shortfall. Review of a new member of staff’s file confirmed that prior to starting work in the home, prospective staff go through a selection process and references and criminal record bureau clearances are obtained. DS0000012753.V306579.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. Sufficient management hours need to be provided to ensure effective management and oversight of the home and support for residents’ and staff. EVIDENCE: There is no registered manager in post at the present time; therefore standard 37, which relates specifically to the registered manager, has not been assessed. However the adequacy of the management arrangements has been considered as part of the inspection. An acting manager who is also an experienced registered manager of another Mencap home has managed the home. Difficulties have been experienced maintaining the agreed supernumerary capacity of the manager and support from a deputy manager due to vacancies and staff shortages in both homes. Discussions during the inspection confirm that the acting manager has worked hard with staff to address some of the shortfalls and improve the quality of life for residents. DS0000012753.V306579.R01.S.doc Version 5.2 Page 24 However there were indications that more protected time for the manager and deputy needs to be allocated to ensure consistent management and leadership The acting manager advised that a continuous improvement plan has been developed as part of the quality assurance processes. This plan was developed in conjunction with staff at a staff meeting. The plan was noted to include some of the issues raised in this report such as care planning and staffing. A representative of the organisation carries out monthly visits to review the quality of care provided. A quality audit which is a detailed audit of the services and care provided was carried out by the organisation last year at Cottingham Road however discussion with the acting manager identified that the findings had not been made available to her to incorporate in the improvement plan. The pre-inspection questionnaire submitted by the acting manager confirmed that regular maintenance checks and servicing is carried out on equipment such as fire equipment, electrical appliances and the central heating boiler. Discussion with staff confirmed that relevant health and safety training is being provided such as first aid, fire safety, food hygiene and movement and handling. It was identified during the inspection that a new member of staff was carrying out movement and handling of residents prior to receiving training. Training had been booked for the member of staff and it appeared that trained staff were observing the practice however to reduce the risk to residents and the member of staff the inspector advised that training should be received prior to carrying out these duties. DS0000012753.V306579.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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X N/A X 2 X X 3 X DS0000012753.V306579.R01.S.doc Version 5.2 Page 26 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 12 (1) (a & b) Requirement Timescale for action 13/10/06 2. YA23 13 (6) 3. YA33 18 (1) (a) Care plans must be reviewed regularly and updated each time needs change to ensure that they reflect the current needs of residents’. (A similar requirement with a timescale for compliance of 30/12/05 has previously been made.) Payments made to the ‘car fund’ 13/10/06 for purchase of a car used by residents’ must be audited and arrangements made to ensure that no resident is financially disadvantaged. Sufficient Staff must be provided 13/10/06 to meet Residents assessed needs at all times. (Previous requirement with timescales of 30/06/05 and 15/11/05 have not been fully met) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. DS0000012753.V306579.R01.S.doc Version 5.2 Page 27 No. 1. 2. 3. 4. 5. Refer to Standard YA7 YA14 YA19 YA20 YA24 YA27 Good Practice Recommendations Care plans should evidence how any decisions that have been made on residents’ behalf have been arrived at and who has been consulted. Residents should receive any necessary staff support to enable them to take part in regular leisure activities. Information relating to residents health should be consistently recorded and demonstrate regular monitoring of health care needs with any necessary follow up action. Practices in relation to the administration of medication should be reviewed with advice taken from the pharmacist. The adequacy of the premises in relation to meeting residents’ needs should be kept under regular review in conjunction with placing authorities. Findings of the service audits carried out should be incorporated into the continuous improvement plan to provide a more effective quality assurance programme. 6. YA28 YA39 DS0000012753.V306579.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000012753.V306579.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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