Inspection on 25/06/07 for Coveham

This inspection was carried out on 25th June 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Coveham 06/12/05

Coveham 04/05/05

Coveham 11/11/04

Coveham 02/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Coveham Annyards Road Cobham Surrey KT21 2LJ Lead Inspector Christine Bowman Unannounced Inspection 25th June 2007 12:00 Coveham DS0000034623.V335304.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 Coveham DS0000034623.V335304.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. Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coveham Address Annyards Road Cobham Surrey KT21 2LJ 01932 794600 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) Surrey County Council - Adults & Community Care Mrs Carole Ann Gardner Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (1) of places Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2005 Brief Description of the Service: Coveham is a purpose built local authority home providing accommodation for twelve residents. The home is located in a residential road in Cobham and has easy access to shops, public transport and other local services. The accommodation for residents is provided on two floors and all the bedrooms are single. The communal space provided comprises of two bright and comfortably furnished lounges, a large dining room with a computer area sectioned off, a well-fitted kitchen, a communal laundry and suitable bathroom/toilet facilities. Recent developments have reduced the numbers of residents living at the home from 20 to 12 and there are plans for the final number accommodated to be 10. Self-contained flats have been built for residents moving on to supported living with the homecare service provided by another Surrey County Council agency. The home has retained some of the large garden, which was originally mainly lawn, and has an outdoor patio area with a barbecue for summer entertainment. There are parking facilities in the front drive for up to ten cars and the home has its own vehicle for use by its residents. The fee is £641:82 per week. Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was conducted as part of a key inspection using the Commission’s ‘Inspecting for Better Lives’ (IBL) process. The site visit took place over six hours commencing at 12.00 pm and ending at 18.00 pm and was undertaken by Ms Christine Bowman, regulation inspector. Lunch was in the process of being prepared and one resident was busy helping in the kitchen when the site visit commenced. The manager was on annual leave, but the assistant team manager was available for most of the day and assisted with the inspection process. A number of staff were interviewed and spoken with throughout the day. More residents were at home than would usually have been because one of the day centres was closed for the day. One resident kindly offered a tour of the shared accommodation and two residents allowed their bedrooms to be viewed. All the residents were spoken with throughout the day. The residents and staff were friendly, welcoming and helpful. Some residents agreed to complete comment cards for a second time because the preinspection data could not be found and the staff kindly photocopied all the other documents. Two residents’ files were inspected including their person-centred plans, reviews, risk assessments, medical information, financial records and weekly schedules. The recruitment process of two staff members was inspected and the staff training and development logs viewed. Menus, staff rotas, health and safety certificates and the complaints and compliments log were sampled. The pre-inspection material supplied by the home and information received since the previous key site visit, as recorded on the inspection record, was also used in compiling this report. Since the previous site visit changes had taken place in the organisation of the home creating three flats for the use of residents, who had moved on to supported living and plans were in place for another flat to be created. The flats are separate from the home, having their own entrances and support for the residents is supplied by a domiciliary care agency supplied by Surrey County Council. Thanks are offered to the management, the staff and residents of Coveham for their assistance and hospitality on the day of the site visit and to all those who completed comment cards for their contribution to this report. What the service does well: The service is good at treating the residents as individuals, ensuring their person-centred plans cover all their assessed needs and that the residents are involved in drawing them up. The person-centred plans are well illustrated with photographs, symbols and describe in clear language an holistic plan of care for the individual, whose likes and dislikes, opinions and aspirations are Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 6 fully explored. Those things, which mean the most to the individual, are described in their own words and the support required to bring those wishes to fruition. The care plans are reviewed regularly confirming that the resident’s changing needs are being addressed. Minutes of the review meetings are recorded from the resident’s point of view and in a format accessible to them. Health action planning ensures that the individual’s personal and healthcare needs are assessed and that support was provided in the way that they preferred and required. The home has strong links with the local community, make good use of the facilities and resources available and the residents have a full programme of activities based on their individual needs and choices. ‘I like going to church and going out in the minibus for a drive’, one resident commented. Another resident said they enjoyed artwork and attended an evening art class. One resident commented, ‘I like Lockwood Day Centre and I wouldn’t like to move. I go to The Causeway, Lockwood Social club. I go swimming on Friday, to football on Sunday and every two weeks I go to see my family. I like it here.’ Throughout the day, the staff were observed interacting with the residents and the relationships were warm, supportive, friendly, encouraging and respectful. What has improved since the last inspection? ‘The staff rota had been changed since the numbers of residents had been reduced to enable more one-to-one time between 10:00 am and 4:00pm for individual residents to be accompanied in the community or receive support in the home’, the assistant manager stated. Two personal computers had been donated to the home for the resident’s use and had been set up in a partitioned area at the end of the dining room. Residents were observed using the computers with staff support. The menus had been improved and the home had committed itself to the principles of healthy eating. A pictorial menu was available to inform the residents, who were involved in planning the menu by using picture cards. The dining room had been refurbished and the residents had chosen the colour schemes and style of furniture. Part of the original large garden had been lost in the building of the new flats, but resources had been set aside to create an attractive, paved outdoor living area with tables, chairs, a barbecue and a fishpond feature. Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 7 What they could do better: 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. Coveham DS0000034623.V335304.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 Coveham DS0000034623.V335304.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. When published, the recently reviewed Residents’ Brochure will include sufficient information, in a suitable format, to enable prospective residents to make a decision about the suitability of the home to meet their needs. Residents’ diverse needs are assessed prior to the offer of a placement to ensure the home is able to meet them. EVIDENCE: The Service User Guide (Residents’ Brochure) was in the process of review for taking account of the new legislation with respect to the inclusion of fee information and due to changes in the organisation of the home, the assistant team manager stated, and when published it would contain symbols and photographs to enable the residents and prospective residents to access all the information about the home they would need. The Statement of Purpose had been recently reviewed and included all the required information. The residents, who completed comment cards, confirmed they had enough information about the home prior to moving in and that the move had been made from their choice. One resident stated they had visited several times before moving in and another stated, ‘My mum said it was good and she likes it.’ Two residents’ files were inspected and both included care management assessments and up-to-date care plans. The assessments covered all areas of Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 10 need including spiritual and social and included the resident’s likes and dislikes so that individual person-centred care plans could be compiled from them. The assessments were signed by the residents and their representatives to confirm their involvement. There had been no new admissions over the last two years. Coveham DS0000034623.V335304.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): Standards 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to ensure that residents are involved in the reviews of their changing needs and that the information is recorded in a format, which is meaningful to them and clear to the staff. Residents are supported to make decisions about their lives and to take the risks associated with an independent life-style. EVIDENCE: The care files of two residents were viewed including their person-centred plans, goal plans, risk assessments and the most recent reviews. Care plans included spiritual needs, social contacts, expression of sexuality, diet, likes and dislikes, communication, mobility, daily living skills, employment, use of community and awareness of dangers. Strengths and limitations were recorded and risk assessments compiled to address issues showing actions in place to reduce risks, monitoring of the risk, review date and signatures. Goal plans were time limited, clear and achievable. Some resident’s comments included, ‘I’d like to make a good curry,’ ‘I’d like to get to know more people’, ‘I’d like to sing or play in a band’, and ‘I need more space in my room to do my pictures and more shelves.’ Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 12 The care plans viewed had been reviewed within the last six months, which confirmed the resident’s changing needs were being addressed. Minutes of the review meetings were recorded in a person-centred way in that it was written from the point of view of the resident. Photographs were included of those present including the care manager, key worker, relatives/representatives and the resident. Resident’s comments were recorded throughout the reviewing of all aspects of their care plan from self-care, domestic skills, community skills, leisure, and communication through to health. Symbols and words were used throughout to make the documents accessible to the residents and they had been signed to confirm acceptance. Key workers were allocated to all residents to offer continuity of support and residents’ meetings offered a forum for residents to make their views known and influence the running of the home. The minutes of the meetings were in suitable symbolic format with photographs and distributed to all residents, a staff member stated. Coveham DS0000034623.V335304.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): Standards 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to live full and integrated lives in accordance with their wishes. They have access to appropriate leisure and cultural activities, maintain and develop personal relationships and are part of the local community. A varied and wholesome diet is available to the residents. EVIDENCE: The majority of the residents attended Day Service Provision four or five weekdays at four separate locations. This information was recorded on the weekly activity schedule. ‘One resident had retired themselves from attending this provision’, a staff member stated, ‘and they enjoyed helping around the home and taking on responsibilities such as emptying the dishwasher, laying the tables and putting the bins out. They also enjoyed being taken out for a drive in the home’s minibus and going to church. Activity schedules were varied according to the individual’s needs and wishes and, ‘the rota had been changed since the numbers of residents had been reduced to enable more oneto-one time for individual residents’, the assistant team manager stated, ‘to be accompanied in the community or receive support in the home’. On the day of Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 14 the site visit one resident had one-to-one support to go to the Drop In Centre in Walton to play softball and have lunch out and another resident received one-to-one support with a home day task of their choice. Another resident was accompanied to attend an art class in the evening and two residents went out with a staff member to do some food shopping. A resident, who had been invited to a dinner-dance recently, said they had spent a day out preparing for it by going to the hairdressers and shopping for and choosing a new dress and accessories with their key worker. Regular activities and clubs included social clubs organised in the evenings at day centres, community living skills, drama classes, the hydro pool, the church group, seasonal crafts, swimming classes, cinema club, monthly disco, music workshop and pub trips. Residents spoken with confirmed they engaged in a variety of activities of their choice. One resident stated that he had asked for changes to his bedroom to make space for storing his easel, which he used for artwork. A resident, who led the tour of the premises, stated that they saw their relatives frequently and were picked up at the home and taken out. Another resident stated that they went on holidays with their family and liked to see their sister. Residents’ rooms contained many personal items including photographs of family, friends and memorable occasions and evidence of individual interests. The residents had keys for their rooms and a small comfortable and well-furnished second sitting room was available should they wish to entertain guests in private. Two staff members confirmed that residents were encouraged to develop relationships of their choice. Throughout the day, the staff were observed interacting with the residents and the relationships were warm, supportive, friendly, encouraging and respectful. One staff member supported two residents to use the personal computers, which were set up in a partitioned area at the end of the dining room. Lunchtime was a social occasion, and everyone gathered in the large, but homely dining room to enjoy the meal together. Healthy eating is encouraged, a member of staff stated, and everyone was aware of the recommended five items of fruit or vegetables per day. A pictorial menu was available to inform the residents, who were involved in planning the menu by using picture cards. Coveham DS0000034623.V335304.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): Standards 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive support according to their needs and wishes and positive action is taken with regard to health issues. Safe procedures are in place with respect to the administration and storage of medication. EVIDENCE: Health action planning ensured that individual’s personal and healthcare needs were met and that support was provided in the way that they preferred and required. Residents’ files sampled contained a comprehensive checklist of health needs. Plans were set out to include the identified needs, the action required to improve, the person responsible and the review date. Residents had been registered with a General Practitioner, dental practitioners and various opticians. One resident had support from a dietician and a private chiropodist provided a service to the majority of the residents. A specific community nurse, occupational therapist and clinical psychologist were available to residents. All the staff that administered medication had received training and a list of specimen signatures was kept for completing the MAR sheets. All the residents had safe storage for their medication in their bedrooms and most of the medication was blister-packed at the local pharmacy. Records were kept of Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 16 the receipt and disposal of medication and all transactions were signed and upto-date. Coveham DS0000034623.V335304.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): Standards 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ views are listened to and acted upon. Policies, procedures and training are in place to protect residents from abuse, neglect and self-harm. The shortfall in the training of some staff could potentially put residents at risk. EVIDENCE: Regular group meetings, the minutes of which were recorded in photographs and symbols and distributed to all residents, provided a forum for resident’s views to be heard. Residents, who completed comment cards, confirmed they thought the carers always listen and act on what they say. Some of the topics discussed included special occasions and holidays, taking responsibility for completing domestic tasks and the building works. Residents confirmed they knew who to speak to if they were not happy. One commented that they would speak to their key worker, the manager or the staff in charge of the shift; another stated they would speak to any of the staff and a third would choose to speak to a particular member of staff. All the residents were allocated key workers and all those, who completed comment cards, stated they knew how to make a complaint. A symbolic complaints procedure had been produced, which was accessible to the residents. The records retained at the home contained no complaints but a compliment from a parent had been recorded with respect to the care and support extended to their daughter throughout a stay in hospital. The Commission for Social Care Inspection since the previous site visit had received one anonymous complaint. Concerns had been raised about the effect of the changes with respect to the move to supported living for some of the ex-Coveham residents now accommodated in flats and receiving support Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 18 from a local authority domiciliary care agency. The complainant was concerned about the vulnerability of the residents, the fact that they had lived at Coveham for a very long time and would only be receiving support for part of the day. The complaint was sent to the provider, who carried out an investigation and reported the findings to the Commission for Social Care Inspection. The provider stated that the reduction in the number of residents at Coveham had been a planned change to meet registration standards. The layout of the building allowed for a different configuration to be set up with little disruption to the residents and the new supported living units are intended to provide a more individualised and specialist support package. Care management had taken the lead with the planned changes for individual residents through a review of their needs. The resulting care plans are based on information received from all those involved with the residents including health professionals, day service staff, Coveham staff, family members and with input from the individual residents. This process has ensured that any changes to the care arrangements for each of the residents moving to supported living are appropriate, maximise independence and manage risk. The home had a ‘Safeguarding Adults’ policy and staff training was provided in the Protection of Vulnerable Adults. However the training audit showed that a number of bank and night staff had not received this training and other staff required updated training to reflect the changes in the local authority policy and procedure, which was reviewed in 2005. No safeguarding referrals had been made since the previous site visit. Coveham DS0000034623.V335304.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): Standards 24,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a homely, comfortable and clean environment, which meets their needs. Identified risks compromise the safety of the residents. EVIDENCE: A partial tour of the premises confirmed that the home met the needs of the residents in a comfortable and homely way. The home had originally been purpose built to accommodate twenty residents, but some bedrooms had been used in the conversion of the flats for supported living. A large well-furnished communal sitting room was provided, which was nicely decorated and provided entertainment for residents in the form of a television, DVD, video player and a music centre. A door led from this room to the outdoor paved area with tables, chairs and a barbecue. The building of the flats had taken up a large portion of the original garden but resources had been set aside to create this attractive and people-friendly space with a fishpond feature. The dining room adjoined the sitting room from the other side and new furniture had been purchased recently, the assistant team manager stated, the residents had been involved in choosing the style of the furnishings and the colour of the décor. The furniture was of good quality, solid but domestic. The food was Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 20 served through a hatch from the kitchen, which was large, well equipped and clean. There was a second, smaller sitting room or quiet room, which, the resident conducting the tour stated, could be used for entertaining visitors. The downstairs bathroom was in need of refurbishment and a staff member confirmed it had been included in the programme of planned maintenance and renewal and that a walk-in shower was part of the new design. Paper towels were available in the downstairs toilet fostering good hygiene practices, but there was no means for their disposal, leading to residents leaving the used towels around the room. Several offices were available including the administration office, the staff office, which was due to be redecorated, a staff member stated, and the assistant team manager’s office, which was in the process of being built up into a training resource centre for the staff. There was a well-equipped clean laundry room, which was clean and hygienic and policies were in place with respect to infection control. A full fire risk assessment had been carried out on the premises by an independent agency and the health and safety officer had informed the provider of the results. Outstanding work was required with respect to all levels of risk, but those items assessed as high risk, must be completed within the stated timescales to protect the residents. The environmental health officer had visited since the previous site visit and the home had gained a silver award. Coveham DS0000034623.V335304.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): Standards 32,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team are committed, reliable and well motivated, but shortfalls in the mandatory training of some staff leaves them ill-equipped for the caring role. Safe recruitment processes protect the residents from the risk of abuse. EVIDENCE: Observations of the staff working with the residents throughout the site visit confirmed that relationships were respectful and that residents were listened to and their wishes acted upon. Throughout the day staff were seen supporting residents at the lunch table, using the computer, working in the kitchen, preparing for a shopping trip and generally giving positive attention to the residents. A comment card from bereaved parents of an ex resident of Coveham stated, ‘the staff were always on hand to attend the hospital for meetings and to visit our daughter at the hospice – we couldn’t have asked for more unstinting and sympathetic support in our time of distress’. Residents who completed comment cards confirmed that the carers always listened to them and acted on what they said and one resident stated, ‘we talk a lot.’ Of the twenty-four staff listed on the training audit, there was evidence of only seven either having completed or in the process of completing a National Vocational Qualification. This included five of the twelve regular daytime staff, Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 22 one of the three night care workers and one of the eight bank staff. In order to professionalize the workforce and to ensure a competent and qualified staff team supports the residents, this ratio should be improved upon. The assistant team manager confirmed that all newly recruited staff, including bank and night staff completed the skills for care common induction standards and that this included three units of the Learning Disability Framework Award. Evidence to support this was available on the records of two recently recruited staff. The staff files sampled were in need of organisation, binding to protect the documents and audit sheets for all files to record the contents. Finding the evidence to confirm safe recruitment practises was time-consuming and some documents were missing, which the assistant team manager was required to confirm receipt of after the site visit. The main reason this was not straight forward was that the local authority take responsibility for some of the recruitment procedures and retain the original documents. Part of the application form, which recorded the referees and the second reference was missing from one file. A telephone call to human resources confirmed the information was available and that copies would be sent to the home. The receipt of this information was confirmed later. Copies of Criminal Records Bureau checks were retained in personnel files and a recommendation was made that the CRB website should be accessed for advice on the storage and destruction of CRB checks. One newly recruited staff member had stated work prior to the receipt of a clear CRB check and there was no evidence on file to confirm that a Protection of Vulnerable Adults First had been obtained. The assistant manager printed off a copy of an e-mail from the responsible individual confirming the receipt of a clear POVAFirst check, which had been received prior to the staff member taking up post. The assistant manager stated that recruitment was in progress currently and that the local authority advertises the posts nationally, but do not provide relocation packages for care staff, which means that some seemingly potential new staff do not continue with the process. There was evidence of some excellent practice in the recruitment process in that three staff conducted interviews and records were retained of the interviews including questionnaires and results. Residents also took part and their comments were recorded including, ‘nice, happy and calm,’ and, ‘good staff’. Equal opportunities monitoring forms were completed and health checks completed by Occupational Health. The minutes of team meetings, which were conducted on a monthly basis, confirmed that training sessions took place and some of the topics included autism, health action planning, and talks conducted by a clinical psychologist and the Community Mental Health Nurse. Staff, who attend courses outside the home are also expected to update the group at the team meeting, the assistant team manager stated. Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 23 The training audit revealed gaps in mandatory training including food hygiene, infection control, health and safety, fire safety, moving and handling and the protection of vulnerable adults. Some care bank and night care staff had no recorded mandatory training. A training needs matrix should be drawn up showing the dates of mandatory training and when the up-dates are due for all staff to ensure the staff are suitably trained for the work they are to perform. A wide range of relevant training was available to the staff and some of the courses accessed included equality and diversity, effective communication, Makaton, autism awareness, Downs and dementia, Epilepsy awareness, person centred planning, bereavement and loss, risk assessment, and reporting and recording. Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed in the best interests of the residents, whose views are sought. A formal quality assurance system is not in place to engage all stakeholders in the future development of the home. Good health and safety systems are in place but urgent action is required by the provider to safeguard the residents. EVIDENCE: The registered manager had many years of experience in social care and had recently undertaken the registered managers award. Organisational change had been well managed at the home throughout the eighteen months of disruption due to the building work carried out at the site and staff commented on the support they received from the managers and how the residents had been supported throughout the changes. Meetings had also been arranged at the home for resident’s families and carers to offer reassurance, the assistant Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 25 team manager stated. Good teamwork was observed on the day of the site visit with responsibility delegated appropriately to staff members. The views of the residents were sought in regular group meetings, the minutes of which were viewed. Photographs and symbols ensured the residents were able to access the information and each resident was supplied with a copy, a member of staff stated. The residents’ care plans were regularly reviewed and also recorded using symbols and photographs and included input from significant others and social and healthcare professionals involved. The annual quality assurance system of questionnaires had not been completed this year as priority had been given to managing the changes, but internal audits had been carried out and a development plan was in place, the assistant team manager stated, but it was not accessible on the day of the site visit due to the manager being on annual leave. Records of Regulation 26 monitoring visits were not up to date, although the staff confirmed they had taken place. The staff member with delegated responsibility for health and safety kept the records in good order and demonstrated that systems were in place to protect the residents. A poster was displayed in the staff office with respect to individual and management responsibilities for health and safety. Records sampled included accident records, which were stored appropriately, portable electrical equipment testing, fire alarm testing, emergency lighting, fire evacuation practice, the Legionella certificate, water temperature checks and food temperature checks, which were all up to date. A full environmental risk assessment was viewed, which had been carried out by an independent agency and categorised risks as high, medium and low. The health and safety representative had raised the awareness of the provider with respect to the necessity of responding in a timely manner to the number of high-risk items identified. Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 27 No 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 YA35 Regulation 18(1)(c) Requirement Timescale for action 25/12/07 2. YA39 3. YA24 4. YA43 All the staff working in the home must receive training appropriate to the work they are to perform in the best interests of the residents. 24(1)(2)(a)(b) An annual quality assurance 25/08/07 (5) system based on anonymous surveys completed by residents, their relatives and advocates and stakeholders in the community should be completed and results used to inform future development. 4(a)(c) Items identified in the fire 25/07/07 risk assessment, as high risk must be dealt with in a timely manner to protect the residents. 26(4)(c) A written report with respect 25/07/07 to the monthly, unannounced visits on behalf of the provider must be available at the home for reference. Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA35 YA34 YA34 Good Practice Recommendations A staff-training matrix should be drawn up showing when the staff have accessed mandatory training and when the updates are due. The staff personnel files were in need of organisation and some form of binding to ensure safety of the documents. The CRB website should be accessed for advice on the storage and destruction of CRB checks and the retention of proof of POVAFirst checks to confirm safe recruitment for the safety of the residents. The ratio of staff having achieved or in the process of achieving a National Vocational Award Qualification should be improved to ensure that qualified and competent staff support residents and to professionalize the workforce. 4. YA32 Coveham DS0000034623.V335304.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Coveham DS0000034623.V335304.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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