Inspection on 01/03/07 for Cragside House

This inspection was carried out on 1st March 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cragside House 11/07/07

Cragside House 24/11/05

Cragside House 01/06/05

Cragside House 24/11/04

Cragside House 21/04/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Cragside House 207 Scar Lane Milnsbridge Huddersfield West Yorkshire HD3 4PZ Lead Inspector Alison McCabe Key Unannounced Inspection 1st March 2007 11:00a Cragside House DS0000026306.V320874.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 Cragside House DS0000026306.V320874.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. Cragside House DS0000026306.V320874.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cragside House Address 207 Scar Lane Milnsbridge Huddersfield West Yorkshire HD3 4PZ 01484 460051 01484 460400 enquiries@cragsidehouse.co.uk 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) VALEO Limited Miss Helen Thomas Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Cragside House DS0000026306.V320874.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specific service user over the age of 65 in the category of LD(E), named on variation dated 29th December 2006, may reside at the home. 24th November 2005 Date of last inspection Brief Description of the Service: Cragside House is owned and managed by Valeo Ltd, a private company. It is a care home for 9 people who have learning disabilities and associated challenging behaviours. The home is located just outside Huddersfield, close to local amenities and a regular bus service. The current scale of charges at this home is £1500 - £2500 per week. The service provider ensures that information about the service is available to prospective service users and the current service users by way of the home’s Statement of Purpose, the Service User Guide and through CSCI inspection reports. Cragside House DS0000026306.V320874.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this key inspection, a visit was made to Cragside House by one inspector between the hours of 11.00 am – 6.45 pm. In addition to the visit, information used to inform the inspection includes notifications received from the home about any accidents, incidents or events that affect the wellbeing of residents, the pre-inspection questionnaire submitted to CSCI prior to the site visit, completed questionnaires from the relatives and service users (with support) giving views about the quality of the service. Questionnaires were sent to seven service users – three have been returned. Two were completed by service users’ keyworkers on their behalf and a service user’s father completed one; six relatives - three have been returned; four visiting professionals - none have been returned; one GP – this was not returned. Some comments and feedback from the completed questionnaires have been included within the main body of this report. Feedback from relatives of service users is generally good with all stating that their relative usually gets the agreed or expected care and that staff usually have the right skills and experience to look after their relative. The inspector had the opportunity to talk to the manager and staff on duty. Due to the nature of the service users’ disabilities, verbal feedback about what it is like to live at Cragside House is not possible. The inspector therefore spent time observing care practice and interaction between staff and service users. Communal areas and service users’ bedrooms were seen. Records relating to service users, monies, staff training, staff recruitment and staff rotas were examined as part of the site visit. Medication and records relating to medication were examined. Since the last inspection, there have been a number of changes at Cragside House. Three service users have moved into the Valeo home next door (The Lodge) and three service users from The Lodge have moved into Cragside House. This move had taken place a few weeks before the inspection visit, therefore staff and service users were still in the process of adapting to the changes. Some concerns were expressed by staff about how all service users’ needs would be met as all service users now living at Cragside House have very complex needs. There was evidence in records that staff have had the opportunity to raise concerns with the Director of Care and that close monitoring of how service users are settling in is taking place. The registered manager is due to go on maternity leave at the beginning of April, however good arrangements have been made to provide adequate management cover in her absence. The inspector would like to thank the service users and staff for their cooperation and hospitality during the site visit. Cragside House DS0000026306.V320874.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: All identified risks to service users need to be properly documented and assessed. More support should be given to service users to keep them engaged in meaningful activities both at Cragside House and out in the community. The manager and staff must be clearer about when an accident, incident, injury or change in a service users’ health should be reported. Better records must be kept about this. More accurate medication records need to be kept. Cragside House DS0000026306.V320874.R01.S.doc Version 5.2 Page 7 Staff should to continue working towards obtaining NVQ qualifications in care. 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. Cragside House DS0000026306.V320874.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 Cragside House DS0000026306.V320874.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs are assessed prior to them moving into the home. EVIDENCE: Records relating to two service users were examined as part of the key inspection. Both contained evidence that pre-admission assessments had been completed prior to service users being admitted to the home. Cragside House DS0000026306.V320874.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are supported to take reasonable risks and make choices with support and their needs are reflected in their individual care plans. EVIDENCE: Individual care plans that were examined contained excellent detail about how individuals’ needs should be met. Service users’ files were well organised and it was easy to access information. There was evidence in the records that a person centred approach had been adopted in formulating the care plans. Service users’ relatives/advocates had been consulted as part of the process and there was evidence of regular reviews. It was noted that some documents had not been dated or signed. In order to easily track progress, be aware of the author of documents, and ensure that the most recent version of a care plan is being implemented, it is necessary to date and sign all documentation. A recommendation has been regarding this. Cragside House DS0000026306.V320874.R01.S.doc Version 5.2 Page 11 The service users living at Cragside House all have complex needs and are very reliant on staff to support them in making choices about their lives. Staff described how they would offer choices to service users, for example, offer a choice of two boxes of breakfast cereal. The kitchen area of the home is split into two parts allowing for the area with the cooker and food stocks to be shut off, whilst leaving a food preparation area and sink that can be accessed by service users with staff support. The manager reported that service users are encouraged and supported to make snacks and drinks in this part of the kitchen. During the site visit, a senior member of staff was observed enabling two service users to access this facility and some staff were observed offering choice of drink or activity to service users. Records examined showed that service users are supported to take reasonable risks and appropriate assessments had been completed giving guidance to staff about how to minimize identified risks. Discussion took place with the manager about an identified risk to a service user that had not been recorded or considered within a risk assessment. The manager agreed that a risk assessment would be developed regarding this matter. Cragside House DS0000026306.V320874.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported to maintain fulfilling lifestyles in that good support is offered to maintain contact with families, and service users’ cultural dietary needs are met, however not all service users are involved in meaningful daytime activities. EVIDENCE: At the time of the site visit, service users’ opportunities to access community based leisure or educational activities was limited due to staffing difficulties. The manager explained that this was a temporary difficulty as regular staff were being used to support a service user on a twenty-four hour basis whilst an inpatient in hospital. All staff spoken to confirmed that, usually, service users have many more opportunities to go out than had been the case for the past few weeks. Records examined confirmed this. Four of the seven service users attend Valeo day services. The three remaining service users choose not Cragside House DS0000026306.V320874.R01.S.doc Version 5.2 Page 13 to attend day services. During the site visit, service users were observed to spend long periods of time unengaged in meaningful activities. Feedback in a survey from a relative suggested that more consistent efforts be made to encourage their relative to go out in order to alleviate boredom. The registered manager acknowledged that further efforts need to be made to keep service users occupied both in and outside of the home. A recommendation is made in respect of this. Records examined indicate that service users are supported to maintain contact with their families. Completed surveys from relatives of service users confirm this. Some restrictions are placed upon service users living at this home in order to protect them from harm, however the manager reported that any restrictions were agreed at review and appropriate risk assessments were in place. Evidence of this was seen in the records. Some staff were observed to knock on bedroom/bathroom doors prior to entering in order to ensure the privacy of service users. Menus were provided to the Commission for Social Care Inspection with the pre-inspection questionnaire. These show that a balanced and varied diet is offered to service users. Plenty of fresh food was available at the time of the visit, including a good range of fruit and vegetables. The manager and staff reported that service users are supported to get their own breakfast although, due to the complex needs of the service users, staff generally prepare hot meals. On the day of the visit, service users had beans on toast for lunch and fruit or yoghurt for pudding. A service user’s cultural needs are met in that Halal meat is provided. Cragside House DS0000026306.V320874.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Service users’ personal care needs are met, however their health needs are not met consistently and medication records are incomplete. EVIDENCE: Excellent information was available in both care plans examined, setting out how the service users prefer to be supported with their personal care and detailing their preferred routines. The manager demonstrated a good understanding of service users’ needs and described a flexible service in terms of when service users get up, go to bed, eat, have a bath etc. Evidence of this was seen in the records examined. Records examined indicate service users’ health care needs are usually monitored and that service users are supported to attend appointments with healthcare professionals. Through discussion with staff and the manager, there was evidence that staff had taken the appropriate steps following a recent change in the health of a service user. However, there was evidence in Cragside House DS0000026306.V320874.R01.S.doc Version 5.2 Page 15 records that appropriate action to ensure service users’ health needs are always met is not always taken. For example, following an injury to a service user’s head, there was no evidence of any medical follow up in accident records, daily records, night care records or staff handover book. There were also a number of entries in records of unexplained bruising where there was no evidence of medical follow up action being taken. This was discussed with the manager at the time of the site visit and a requirement has been made regarding this matter. Medication and records were examined, however it was not possible to reconcile medication with the records, as staff are not recording medication carried over from the previous month onto the new Medication Administration Record (MAR). Safe systems must be developed so that it is possible to check whether medication has been administered as prescribed. A requirement has been made to that effect. Guidelines are in place describing under what circumstances ‘as required’ (prn) medication should be administered. These contained excellent detail and gave staff clear instructions. The pre-inspection questionnaire states that all staff receive comprehensive medication training within three months of employment and the manager confirmed this. Cragside House DS0000026306.V320874.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. 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 available evidence including a visit to this service. Clear complaints and protection procedures are in place, however potential adult protection issues are not always managed satisfactorily therefore service users are not always adequately protected from possible abuse. EVIDENCE: A satisfactory complaints procedure is in place and the pre-inspection questionnaire indicates that no complaints have been received in the last twelve months. Due to the level of learning disability, service users would require significant support in making a complaint or require a family member or advocate to act on their behalf. Three surveys from relatives, carers or advocates were returned and two of the three indicated that they were aware of the complaints procedure; one was not. However, all indicated that any concerns raised by them on behalf of a service user are always acted upon appropriately. Procedures are in place for the protection of vulnerable adults and staff spoken to were able to give a satisfactory account of how they would respond if they suspected abuse. The organisation has an identified named co-ordinator for adult protection issues. Two referrals have been made to Social Services Information Point regarding a protection issue. The appropriate people were notified and steps were taken to protect the people concerned. Cragside House DS0000026306.V320874.R01.S.doc Version 5.2 Page 17 Whilst examining records of two service users, it was noted that a number of unexplained injuries were poorly recorded and no follow up action was recorded as having been taken. A number of these should have been referred under adult protection procedures. The manager explained that a service user bruises easily, however acknowledged that the recording and lack of follow up action was unsatisfactory. The manager expressed her commitment to address these matters as a matter of urgency with the staff team. Comments received in a relative/carer/advocate survey included concerns for the safety of a service user after a number of minor accidents. Staff training records indicate that most staff have received training in the protection of vulnerable adults, and those who haven’t are due to attend on 17th April 2007. Service user monies were checked and were securely stored, well recorded and balanced with records kept. Good systems are in place to safeguard service users from financial abuse. Physical intervention plans are in place for some service users and include information about aggressive behaviours that are displayed, de-escalation techniques and physical intervention techniques that can be used. A record of who has developed and compiled the plan is included and the physical intervention trainer approves the plans. The date of implementation and review date of six months later is recorded on the plans. In order to improve the plans further, in accordance with Department of Health guidance, multidisciplinary agreement should be sought in consultation with the service user, where possible, their carers or advocates and a record of this should be kept. The manager needs to ensure that the plans are individualised, as a number of specific elements were the same in each plan while service users have very different needs. A section of the physical intervention plan includes information about health issues that need to be taken into account, however it was identified that an important health issue for a service user had not been recorded, and this must be added. There was evidence that staff had received training in physical intervention that is in line with the British Institute of Learning Disabilities (Bild), although not accredited by Bild as recommended by the Department of Health. A new role has recently been developed and the deputy manager at Cragside House has taken on the ‘Protection of Vulnerable Adults (POVA) Watchdog’ role. POVA watchdog guidelines were submitted along with the pre-inspection questionnaire, and these clearly set out the objectives and responsibilities of this position. This is due to be piloted at Cragside House between 1st March 2007 and 31st May 2007. The registered manager was confident that incident records and staff’s response to unexplained injuries would be closely monitored under the new system. Since the site visit, the Director of Care has visited the home in order to examine those service user records that there were concerns about. It is acknowledged that, upon receipt of information or concerns of an adult protection nature, the provider has a good track record of responding Cragside House DS0000026306.V320874.R01.S.doc Version 5.2 Page 18 appropriately and quickly. The CSCI is confident that the provider will deal with the matters raised during the inspection. Cragside House DS0000026306.V320874.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a clean, comfortably furnished home that is domestic in style and homely. EVIDENCE: A tour of the premises was conducted and, overall, the home was clean, warm and homely. The home is on four levels including the basement. Bedrooms are situated on the first and second floors and the lounge, dining room, kitchen and conservatory are on the ground floor. The laundry is in the basement along with a multi-sensory room and medication room. There is plenty of storage available. Service users have access to large, well-maintained gardens. Most of the service users’ bedrooms are personalised and comfortably furnished. The manager explained that some of the bedrooms are due to be decorated and that service users will be encouraged, as far as possible, to choose colour schemes etc. Although the home is registered for nine service Cragside House DS0000026306.V320874.R01.S.doc Version 5.2 Page 20 users, there are only seven service users currently accommodated. The manager said that there were no plans to fill these vacancies and that discussions were taking place about improving the existing facilities and possibly installing en-suite bathrooms to some rooms. There is plenty of communal space including a large dining room, hallway, lounge and conservatory. The home has the benefit of a multi-sensory room in the basement which is used by service users from other Valeo homes as well as Cragside. The lock on the bathroom door on the top floor did not work, however this was repaired on the day of the site visit. The bathroom on the first floor needs retiling and the bath re-sealing. The manager said that this had been identified and was on the maintenance list. The cover on the bath seat was dirty and unhygienic and arrangements need to be made to ensure this is cleaned on a regular basis. Although staff did attempt to remove the cover for cleaning during the site visit, they were unable to do so. An industrial washing machine and tumble dryer are available in the laundry, which is in the basement. The laundry is well organised and hand washing facilities are available although a paper towel dispenser needs to be installed. The washing machine has a sluice cycle and systems are in place to deal with foul laundry appropriately. The home was free from unpleasant odours. Cragside House DS0000026306.V320874.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users are supported by a trained staff team who are adequately supervised and have had all the required pre-employment checks, however more staff need to achieve an NVQ qualification in order to ensure service users are supported by a suitably qualified team. EVIDENCE: Staff are provided with a range of training relevant to the needs of the service users. Staff training records were examined and showed that most staff have received up to date training. Staff spoken to confirmed this. A rolling programme of training and development is ongoing and the manager demonstrates a good awareness of the training needs of the staff team. Staff training needs are discussed in one to one supervision and annual appraisals of staff. Evidence of this was seen in staff records. The pre-inspection questionnaire indicates that five out of seventeen care staff (28 ) have an NVQ level 2 or above in care. The manager reported that four staff are currently working towards the Learning Disability Award Framework (LDAF) induction and foundation awards and will then commence NVQ training. The Cragside House DS0000026306.V320874.R01.S.doc Version 5.2 Page 22 remaining members of staff are all currently working towards either NVQ level 2 or 3. Some members of staff were observed to demonstrate positive and respectful attitudes towards service users. However, service users were observed to spend periods of time wandering about the home with little interaction from staff. Although some staff appeared to be motivated to engage service users in meaningful activities, this was not observed to be across the entire staff team. The manager and staff reported that morale had been low at the home, in part due to recent changes in service users accommodated, which has impacted on the level of care and supervision that is now required. The manager did say however that staff morale at the home was improving. Staff recruitment records were checked in relation to three members of staff. All the required information was available and well organised. There was also evidence that all staff had received one to one supervision with the manager since January 2007. The manager reported that she had planned to see all staff individually again before she went on maternity leave at the beginning of April. Cragside House DS0000026306.V320874.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a well run home that is maintained to a good standard and where the quality of the service is monitored. However, service users’ health and safety is not always adequately protected in that unexplained injuries/bruises are not always reported, recorded or followed up appropriately. EVIDENCE: The registered manager has worked at the home for eleven years and has been registered as the manager since March 2005. As part of the registration of the manager, it was agreed that she would have completed NVQ level four in management by the end of March 2007. At the time of the visit, the Cragside House DS0000026306.V320874.R01.S.doc Version 5.2 Page 24 manager reported that she had two units remaining and would then have completed NVQ level four. The manager was confident that this would be finished by the time she went on maternity leave at the beginning of April 2007. Arrangements have been made by the provider to cover the management of Cragside House in the absence of the registered manager. A ‘floating manager’, employed by Valeo for several years to cover management shortfalls, will take up the management position until the registered manager returns. A clear list of responsibilities and a development plan has been developed for the deputy manager to ensure good management support and cover throughout the registered manager’s maternity leave. This pro-active approach is positive. The registered manager demonstrated a good understanding of the needs of the service users and the aims of the home and was aware of the impact on both service users and staff following the recent change in service users living at the home. Quality assurance systems are in place. Annual surveys are sent to relatives of service users, and the Director of Care addresses any matters arising with families directly, and with staff where necessary. The Director of Care conducts monthly unannounced visits and a detailed report is sent to the commission with the findings of the visit. These are of a high standard, are detailed, service user focused and include an action plan with timescales for any work to be completed. Service users living at the home are unable to verbalise their views of the service, however the reports demonstrate that the Director of Care spends time observing service users and staff in addition to discussions with staff and examination of service user records. The pre-inspection questionnaire and reports from the registered provider of monthly visits both indicate that health and safety checks and maintenance of equipment have been conducted at the required intervals. Staff training records suggest that they receive training in health and safety, first aid, fire safety as required. Good hygiene practice was observed when staff entered the kitchen and infection control procedures are in place. Comprehensive risk assessments are in place in relation to service users, the building and staff. As discussed under standard 23, a number of unexplained injuries and bruises had not been reported appropriately and follow up action had not been recorded or taken. A requirement has been made in respect of this. Cragside House DS0000026306.V320874.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 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 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 2 X 3 X 3 X X 1 X Cragside House DS0000026306.V320874.R01.S.doc Version 5.2 Page 26 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 YA19 Regulation 13(1)b Requirement Timescale for action 07/04/07 2 YA20 13(2) 3 YA23 13(6) 4 YA23 17(1)a Schedule 3(m) In order to protect the health and well being of service users, where necessary treatment, advice and other services from any health care professional must be sought in the event of injury. In order to protect the health 07/04/07 and well being of service users, accurate records of medicines received into the home and kept at the home must be maintained. In order to ensure the safety and 14/04/07 well being of service users, clear systems must be put into place so that all staff, including the manager, know what action to take in the event of an unexplained injury to a service user. Clear records must be kept. In order to ensure the health and 14/04/07 well being of service users physical intervention plans must include a record of identified health issues that need to be considered in the event of physical intervention being implemented. DS0000026306.V320874.R01.S.doc Version 5.2 Cragside House Page 27 5 YA42 37 c,e Where necessary and in line with adult protection policies and procedures, unexplained bruising or injuries to service users must be reported so that service users’ health and safety is protected. This must include notifying CSCI. 14/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA12 YA13 Good Practice Recommendations Service user records should be signed and dated so that staff can be sure they are implementing the current plan of care. Service users should be supported to participate in a range of fulfilling, valued activities appropriate to their needs and wishes both in and outside of the home so that a good quality of life can be maintained. De-escalation techniques described as part of behaviour management strategies should be individualised so that the use of restrictive physical interventions is minimised as far as possible. In order to improve physical intervention plans, in accordance with department of health guidance, multi-disciplinary agreement should be sought in consultation with the service user where possible, their carers or advocates and a record of this should be kept. In line with department of health guidance on ‘restrictive interventions for people with learning disability and autistic spectrum disorder’ the provider should explore training that is accredited under the BILD Code of Practice. The cover on the bath seat in the first floor bathroom is unhygienic and arrangements should be made for regular cleaning of this equipment for infection control purposes. Paper towels should be made available in the laundry so that staff can dry their hands after washing. In order to improve the standard of the service provided, more staff should be qualified to NVQ level two or above in care. 3 YA23 4 YA23 5 6 7 YA30 YA30 YA32 Cragside House DS0000026306.V320874.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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