Inspection on 03/07/06 for Dalvington

This inspection was carried out on 3rd July 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dalvington 27/07/07

Dalvington 16/12/05

Dalvington 20/05/05

Dalvington 06/12/04

Dalvington 16/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Dalvington 146 Lower Howsell Road Malvern Worcestershire WR14 1DL Lead Inspector P Wells Unannounced Inspection 3 , 6 & 12th July 2006 13:45 rd th Dalvington DS0000018646.V296883.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 Dalvington DS0000018646.V296883.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. Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dalvington Address 146 Lower Howsell Road Malvern Worcestershire WR14 1DL 01886 833424 01886 833684 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) Elizabeth Fitzroy Support Care Home 15 Category(ies) of Learning disability (15) registration, with number of places Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This service is primarily for people with a learning disability but may accommodate people who also have an additional physical disability 16th December 2005 Date of last inspection Brief Description of the Service: The registered provider of this home is the charity Elizabeth Fitzroy Support (EFS). A service is offered to a maximum of fifteen adults between the age of 18 years and 65 years with learning disabilities and some also have a physical disability. Accommodation is divided into three units. Dalvington is the main unit. All facilities are on the ground floor and seven people with moderate to heavy dependency needs can be accommodated. The Willows is a first floor flat within Dalvington that can accommodate two people with minimal care needs and good mobility. The Oaks is a separate house and can accommodate six people who are less dependent than those in Dalvington and more dependent than those in The Willows. The entire complex is registered as one establishment called Dalvington. Mrs Vials was the registered manager but promoted to operations manager in August 2005. A manager, Laurence Dolby commenced in December 2005. The operations manager visits Dalvington, monthly, on behalf of EFS. Mr Neil Taggart is the Director of Operations and the responsible individual. The current weekly fee ranges from £800 - £1600 and there are additional charges for transport, hairdressing, chiropody, papers and some outings. Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. These visits were part of a key inspection. It commenced as unannounced and took place over three days, carried out by one inspector. The visits covered all three units – Dalvington, The Oaks and The Willows, occupied by 14 service users. The key national minimum standards (NMS) were assessed. The inspection also involved reading reports of the visits of the operations manager to the home, comment cards received and the pre inspection questionnaire, which was submitted not fully completed. At the visit discussions took place with the manager, the two assistant managers, staff, service users and briefly the operations manager who was visiting the home. One assistant manager is responsible for Dalvington Unit and is new to the service, having commenced in May 2006. The second assistant manager is responsible for The Oaks and The Willows and has been in post since January 2003. Some of the service users showed the inspector their bedrooms and all the communal parts of the home were viewed. A sample of records, policies and procedures were viewed. As this was the first inspection for the manager and one of the assistant managers, time was spent explaining the process and referring to the National Minimum Standards (NMS) and Care Homes Regulations. Laurence Dolby commenced as manager in December 2005 and earlier this year applied to CSCI to be registered. At the time of writing this report he had been interviewed and registered as manager by CSCI. Just before the inspection visit took place, the management team had moved into new offices, in a separate unit in the grounds, and were still settling in. However the team coped well with the inspection, in the circumstances. The inspector appreciated the co-operation and time of the service users, staff assistant managers and manager. What the service does well: The service provides a permanent home for up to fifteen service users who have differing needs and disabilities in three units – Dalvington (6), The Oaks (6) and The Willows (2). For most of the service users this has been their Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 6 home for more than 12 years. The atmosphere is relaxed, caring and safe. The staff are experienced and most have worked at the home for some years so know the service users well. The service users are offered care and support with their individual needs and there is a range of activities in and out of the home. Comment cards were sent out by the home, on behalf of CSCI. With support from staff, 11 of the 14 service users replied to the 9 questions asked about the service. Overall the service users were happy with their home and service. They also indicated that they had been involved in choosing the home. 3 commented they make decisions about what they do each day, 6 commenting that ‘usually’ they can and 2 ‘sometimes’. 6 replied that they can do what they want to do during the day, in the evening and at the weekend, 4 indicated that this was dependant on staff and vehicle availability and 1 person indicated ‘no’. All the service users replied that they knew who to speak to if unhappy and only 1 was unsure how to make a complaint. 3 of the service users replied the homes were fresh and clean with 8 replying that this was ‘usually’ or ‘sometimes’ so. All the service users responded that the staff treat them well. 7 replied that staff listened and acted on what they said, 4 replied ‘usually’. The 10 relatives who replied were satisfied with the overall care provided and 3 very pleased. 4 replied that staffing levels could be better, 1 had not seen the complaints procedure, 2 had made a complaint and 2 considered they could be kept better informed. 2 GPs responded positively and 1 commented that the service users were cared for in a very caring, friendly, professional and homely way. 7 health care professionals responded that they were satisfied with the overall care provided to the service users. 3 considered that communication could be improved within the staff group to benefit service users. What has improved since the last inspection? A new manager is in post and a new assistant manager for Dalvington. The Oaks now has it’s own laundry and Dalvington a shower room. There is a new unit in the grounds with offices for the managers and a computer room for service users. The mix of service users in Dalvington has been reviewed and the atmosphere is more peaceful. The arrangements for regular physiotherapy for service users have improved. Staff vacancies are filled and agency staff are no longer being used. The home has a group of relief staff to call upon, who know the service users, if there are staff shortages. Dalvington DS0000018646.V296883.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. Dalvington DS0000018646.V296883.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 Dalvington DS0000018646.V296883.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): 1,2,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good arrangements are in place to introduce a service user to the home. However the information about the home needs to be updated. EVIDENCE: The home’s statement of purpose was still out of date and not in a suitable format to give out to representatives of prospective service users. The service user guide was available in two formats but also needed updating. Copies of the revised statement of purpose and service user guide had not been sent to CSCI, as recommended in previous reports and discussed with the manager in May 2006. Most service users had a contract/agreement. The service has a good introductory process for new service users and this was evident from a recent admission. Both the home and social worker had carried out written assessments. There was a suitable, planned and introductory period for the person and discussions took place with his previous carers. The service user’s day placement and regular activities were being maintained. Dalvington DS0000018646.V296883.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): 6,7,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users would benefit from the care planning process being streamlined and developed to reflect a person centred approach with one current individual plan. Regular reviews need to be re-established and minuted. Consideration should be given to how service users can be more involved in making decisions about their lives and evidencing this, as well as service users managing their own finances. All information about service users should be kept in locked cupboards. EVIDENCE: All the service users need assistance with making decisions about their lives and daily routines. Hence the service user plans are crucial to ensure that each service user’s needs are known and met in a consistent manner. Staff were able to give a clear accounts of individual service user’s routine and Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 11 needs. However the sample service user plans viewed, for each unit, varied and some were not always up to date or gave a clear picture of the person’s current needs and choices. There was a lot of information about the service user on the file but sometimes unclear whether the information was still current. It was acknowledged by the new managers that new staff would find it difficult to support a service user based on the file. It was said that a new member of staff would learn from other staff about the care and support each service user needed. Information about each service user was kept in a variety of places, such as – service user file, person centred plan, diary, handover book and activity file. Person centred plans had been introduced for service users but had not been kept up to date and were currently being reviewed. Some service users had had annual reviews and for others, recent reviews were not apparent. The manager had prepared dates for six monthly reviews, one internally and another externally involving the service user’s family and social worker. A recent internal review for a service user was said to have taken place but the minutes were not available. Six monthly reviews, or when a service user’s needs change are considered essential. The system for recording information about a service user should be reviewed and streamlined so that there is an up to date, person centred plan for each service user. Service users were consulted on a daily basis about their routines and activities. Resident meetings were held in each unit and the minutes indicated that these had taken place twice this year. Consideration should be given to these meetings happening more frequently. It was good to hear that in The Oaks pictures were used at meetings to ascertain service users opinions. The feedback from the service users’ comment cards was outlined in the summary at the front of this report and should also be considered. In all the units the service users monies were being kept and managed by staff. Consideration should be given to reviewing this arrangement to assess whether some service users could keep their own monies (in their bedrooms) and be supported by staff in managing their monies. The appointee arrangements with the ex manager need reviewing and preferably so that the current manager is not an appointee for service users. Risk assessments were evident on service user files. The majority of information about service users was kept in locked cupboards. However in Dalvington unit some service user files were observed on open shelves in communal rooms. The manager advised that a lockable cupboard was planned and this would ensure that information about service users is kept safely. Dalvington DS0000018646.V296883.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 good. This judgement has been made using available evidence including a visit to this service. The service users have a range of activities during the week according to their individual interests. More opportunities for going out at weekends should be considered. Service users are given a varied, diet according to their individually assessed needs. However the menus could be developed. EVIDENCE: There were activity organisers in Dalvington and The Oaks who, with the service users and support workers, arrange a programme from Monday to Friday of activities for each service user based on their individual interests. Each service user has an activity record and learning log which is a useful way of noting whether a service user had enjoyed the activity. There is a variety of activities and visits arranged using local facilities – college courses, day Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 13 centres, swimming, sensory centre, library, shopping, fishing, horse riding. Day trips and holidays were also planned with service users and taking place. In the units there were regular music sessions with a therapist or member of staff who plays the banjo. Dalvington have a games room with piano and musical instruments. Also in this unit there is a well-equipped sensory room, the white room, which service users from all the units can use for individual sessions. Other indoor activities include games, painting, skittles, assisting with cleaning. The two service users in The Willows have their own weekly schedules and attend day centres daily. Service users who prefer to have less structured days were also supported. Some service users, relatives and staff advised that when all the service users were at home during a weekend, activities were sometimes limited, according to the number of support staff on duty and drivers available (the activities organisers do not work weekends). Consideration should be given to ensuring there are sufficient staff on duty, and drivers, so that service users can go out. Many of the local community events take place at weekends. Holidays had taken place or were being planned. One service user indicated how he had enjoyed his holiday and had photographs. Maintaining contact with family and friends was encouraged. However not all the service users were in regular contact with their relatives and this could perhaps be further encouraged with a newsletter or key worker contact with relatives. Alternatively advocates should be considered for service users who are not in regular contact with family and friends. Each service user had their own daily routine, which was known and respected by the staff. The staff were observed talking to and interacting with service users, not exclusively with each other. Every service user’s preferred foods and dietary needs were known and meals prepared accordingly. There were menus and a recorded of food provided for each service user. However these records were not always up to date, fully completed, did not indicate a choice of meals or snacks, nor supper. It was pleasing to hear that mealtimes could flexible according to the needs and activities of service users. The support workers (care staff) prepare all the meals and snacks and the majority of staff have basic food hygiene certificates. Further consideration should be given to the menus being more detailed, varied, assessed nutritionally and more home cooked meals prepared rather than using convenience foods. Some staff may appreciate further training in preparing Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 14 meals for service users and details of menus and courses were given to the manager. Dalvington DS0000018646.V296883.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 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 available evidence including a visit to this service. The service users receive appropriate support with their person and health care needs. Implementation of the Worcestershire health action plans for each service user would be beneficial. The medication policy should be reviewed and the staff who administer medication to service users, receive up to date training. EVIDENCE: At these visits it was apparent through reading a sample of the service user plans, discussion with the managers, staff and observation that the service users continue to be offered appropriate support with their personal and health care needs. Staff when assisting service users, assured their safety and privacy. Personal support was observed being given in a discreet manner and staff knew how to assist each service user and to use the equipment. Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 16 Professional help is sought at an early stage if a physical or emotional problem arises. There were various examples of how individual healthcare needs were met in consultation with professionals. Key workers had a detailed knowledge of the personal and healthcare needs of service users. The home has a key worker system and key workers spoken with, were fully aware of how a service user’s health care problem was being followed up. There was a lot of information on the service users’ files about their health but not always clear whether this information/treatment/guidance was current. Charts were kept to monitor a specific problem. The service users were able to access therapists in the community. For example service users had eating and drinking assessments and guidance in their service user plans undertaken by the Worcestershire communication team. Also a physiotherapist is now regularly visiting some of the service users, which has been an asset. Three health care professionals commented that communication could be improved in-house to ensure that guidance given was implemented by staff for the service users. Some of the service users have a photocopy of a Worcestershire health action plans but the original action plans (a book) did not appear to be in use and would be beneficial to service users, as previously recommended. The new management team would benefit from training to introduce these plans and information about the free local training was given to the manager. Since the pharmacist inspector’s visit in June 2006, the storage of the service user’s medication has improved in both Dalvington and The Oaks. All the service users have their medicines administered by staff. It was pleasing to hear that two staff administer medication to service users and both sign the administration chart. The medication policy was dated 1999 and should be reviewed in line with the guidance of the Royal Pharmaceutical Society of Great Britain – The Administration and Control of Medicines in Care Homes. For the administration of homely remedies and covert medication, the policy referred to a local policy but this could not be located. Records indicated that some staff had attended training in the administration of medication and others were attending a one-day course in July 2006. The organisation runs a one-day course and the local pharmacist runs training sessions on the monitored dosage system for staff. All staff that administer medication would benefit from a refresher course with priority given to those who do not appear to have attended a training course. Dalvington DS0000018646.V296883.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 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 available evidence including a visit to this service. Service users are listened to and there are procedures in place to protect them. The management team and staff need further training in implementing the adult protection procedures to support the service users. EVIDENCE: The home has a complaints procedure in various formats for the service users. The manager advised that there had been no complaints this year. There was a log kept of complaints. The comment cards indicated that the majority of service users and their relatives knew of the complaints procedure and how to raise a concern. Suitable procedures were in the home relating to protecting vulnerable adults. However there have been occasions this year when incidents have occurred and not been discussed immediately with Worcestershire Social Services vulnerable adult protection team and CSCI (se page 27 of this report). Also these agencies need to be advised of the outcome/follow up when the service has carried out the investigation. Worcestershire leaflets, giving guidance to staff on reporting abuse or mistreatment of vulnerable adults, were given to the manager. The new management team and staff need to familiarize themselves with the local procedures. Some staff had recently attended training in protecting vulnerable adults and all staff should have this training. Some staff had attended training on managing challenging behaviour and autism. Difficult situations were managed without the use of physical intervention. Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 18 In all the units the service users monies were being kept and managed by staff. Appropriate storage, records and checks were in place. Consideration should be given to reviewing this arrangement to assess whether some service users could keep their own monies (in their bedrooms) and be supported by staff in managing their monies. Dalvington DS0000018646.V296883.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The houses are homely, comfortable, clean and safe for the service users to live in. The recent alterations have improved facilities for the service users. However approval of the completion of the alterations needs to be obtained from building control and an electrician. Staff would benefit from training in infection control. EVIDENCE: The service is located in a residential part of Malvern with shops and amenities nearby. Accommodation is divided into three units. Dalvington is the main unit. All facilities there are on the ground floor and seven people with moderate to heavy dependency needs and mobility problems can be accommodated. The Willows is a first floor flat within Dalvington that can accommodate two people with minimal care needs and good mobility. The Oaks is a separate bungalow and can accommodate six people who are less dependent than those in Dalvington and more dependent than those in The Willows. Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 20 All the units have separate communal rooms lounge, dining room, kitchen, laundry, bathroom(s) and toilet(s). Some of the service users showed the inspector their bedrooms, which were a good size, suitably furnished and personalised with the service users having chosen the décor. Each service user has their own single bedroom with washbasin. The sensory room was very well equipped and a useful resource for all the service users. All the units were visited and were homely, clean, safe and comfortable. The home is set in it’s own grounds with level patio areas for the service users to sit out. The domestic style and atmosphere of the flat was most suitable for the two service users. Since the last inspection work had taken place to improve storage, the toilet and bathroom facilities in Dalvington unit and the laundry and toilet facilities in the Oaks. The latter were in use and beneficial to the service users in this house. In Dalvington the new, spacious, walk in shower room will give the service users a choice of baths or shower and will soon be in use when the ventilation has been completed. There was now a separate place for storing and re-charging wheel chairs. Also a new, temporary building has been erected in the grounds as offices, storage space and a computer room for service users. The managers had just moved into this building. The building control completion and electrical certificates were still awaited at the time of writing this report. The laundries had suitable washing and drying machines as well as sluicing facilities. There was a supply of protective clothing in the home. Training records indicated that none of the staff had received training in infection control - guidance about local training and information was given to the manager. Dalvington DS0000018646.V296883.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): 32,33,34,35,36 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 by committed, caring staff. However the service users would benefit from the staff being qualified, having more support and training opportunities. EVIDENCE: Each unit has it’s own staff group led by an assistant manager with support workers, activity support workers and night staff. The service also has a maintenance person. There had been some staff changes but many of the staff were experienced and had worked at the home for some years. Five staff had left this year and the vacancies in Dalvington filled. A new assistant manager was appointed to Dalvington in May 2006. The Oaks and The Willows were fully staffed and the group settled. The service has a bank of relief staff who are used on a very regular basis in Dalvington and less often in the other two units. Agency staff were not being used, which was pleasing to note. Rotas were available that indicated the staffing arrangements. The staff spoken with were clear about their roles and responsibilities and enjoyed working in this service. Ancillary staff are not employed so care staff undertake cooking, laundry and cleaning as well as caring and supporting the service users. Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 22 Some staff, relatives and service users commented that there are occasions when the units can be short of staff, usually at week-ends which impacts on service users being able to go out. The rotas indicated that there are less staff on at weekends when the majority of the service users are at home. Some health care professionals commented that on occasions communication between the staff could be improved and the new management need to address this to ensure each service user receives the care and support recommended by professionals in a consistent manner. The overall staff group is 40. The manager thought that four staff have an National Vocation Qualification (NVQ) in care, level 2 or above and three staff are on an NVQ course. The service was therefore not meeting the national standard of 50 of staff having an NVQ in care (previous requirement). In The Oaks and The Willows records indicated that all the staff had completed the organisation’s induction programme, which for the majority included the learning disability award framework (LDAF). In Dalvington the records indicated few staff had completed this induction package. The regional induction programme for November 2005 – February 2006 was available. The organisation offers a rolling programme of training courses for both support workers and seniors, which some staff had attended. However the courses are not held locally which makes it difficult for some staff. A training programme for 2006 based on the individual development assessments of the staff group was not available and needs to be considered to ensure all staff have an NVQ in care, up to date knowledge of caring for service users and in safe working practices. Staff spoke of opportunities to attend courses and some had recently attended course on medication, fire safety, autism, effective communication and protecting vulnerable adults. The organisation had a suitable recruitment process and a sample of the staff records indicated that staff recently employed had been vetted. However it appeared from the pre inspection questionnaire that two staff may have commenced work in the service before enhanced criminal record bureau checks had been received. There was no indication on the staff files what arrangements were in place to supervise these new staff whilst awaiting the CRB checks, as recommended. It would be helpful to include questions in the interviews to ensure any convictions, disciplinary action and gaps in an employment history are discussed and noted at the interview. The manager advised that regular supervision sessions were planned for the year with one of the managers. However these sessions had not yet been established bi-monthly, as yet. Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 23 The manager and some of the staff were not familiar with the General Social Care Council code of practice booklet and details were given to the manager to access more copies so that every member of staff can have a copy. Dalvington DS0000018646.V296883.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 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 available evidence including a visit to this service. The manager is committed to ensuring the health, safety and welfare of the service users and staff. The new management team need to ensure that the systems in place are re-established and maintained to support both the service users and staff. The quality assurance programme, training for staff and aspects of safe working practices need to be developed. EVIDENCE: The new manager commenced in December 2005. The four months previous to this, the service had an assistant manager acting up. Mr Dolby is an experienced, trained senior care worker who has worked for various care services for sixteen years with children and adults who have had learning and physical disabilities. He was registered as manager of this home just prior to the inspection. Mr Dolby has agreed to undertake relevant management training, the Registered Managers Award, training in infection control, moving Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 25 and handling. He has also had an intensive induction programme/courses with the organisation. There was evidence some quality assurance processes were in place but not a complete quality assurance programme as outlined in standard 39 and regulation 24. The organisation is introducing the REACH quality assurance tool to the service and staff were assisting service users in completing the surveys. A health & safety was due in August 2006 and the aim was for quarterly meetings to be held in-house. The operations manager visits and reports on the service on a monthly basis. An annual development plan, annual audit of the service and results of previous surveys were not available. The views of families, friends, advocates and professionals involved with the service users had not recently been sought. It was evident that there are useful systems, policies & procedures and good practice in place, which the new management team need to familiarize themselves with, re-establish and maintain. The new assistant manager was carrying out an in-house review of the policies and procedures. The standard of safe working practices was assessed and it was apparent that there were systems in place to ensure the health and safety of the service users and staff. Equipment, gas and electrical services had been checked. Risk assessments for safe-working practices had not been reviewed since February 2005 and were service user focused. The manager agreed to review these assessments, taking into consideration safe working practices for the staff, as well as the service users, on the premises. The service had been using individual accident forms to record accidents. The manager had purchased HSE approved accident books for each unit. However the organisation were about to introduce their own accident and incident report book. The lay out of this book would not appear to protect the confidentiality of each service user, hence the other accident books would be preferable. Water temperatures were being checked and records indicated that the hot water temperatures in the wash basins used by service users varied from 50°C -64°. The recommended temperature from a hot water outlet is 44°C. It was said that some remedial measures had been taken – taps changed and risk assessments carried out for some service users. Consideration should be given to installing thermostatically controlled valves on the washbasins used by service users. The bath temperatures were being recorded as an acceptable, safe temperature. Some staff had received training in safe working practices and further courses needed to be arranged, in particular for infection control, moving and handling, administration of medication as well as refresher courses for other safe working practices. Records indicated that 16 of the staff had a current first aid Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 26 certificate and 9 staff were first aiders. Due to the varying needs and dual disabilities of service users, the service should consider having a first aider, on site, per shift. The fire precautions were being regularly checked and serviced. The fire risk assessment dated 2004 needed reviewing and updating to include the alterations to the premises and new admissions. Fire safety training is on the organisation’s training programme. Staff had received some fire awareness training in-house but not always quarterly, as required. Guidance regarding fire precautions including training for staff, as recommended by the local fire brigade was given to the manager. CSCI have not always been notified of incidents involving service users as outlined in regulation 37. This matter was discussed again with the manager who was reminded that any event in the home that adversely affects the wellbeing or safety of a service user(s) must be reported to CSCI at the earliest opportunity. In some situations the incident will also need reporting under the Worcestershire vulnerable adult protection procedure (see page 18 of this report) Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 27 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 2 2 3 3 X 4 3 5 3 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 3 25 X 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 2 X Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 28 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15,13 Requirement The registered persons must ensure that all the service user plans are kept up to date and reviewed with service users and their representatives every six months or when needs change. (timescale of 28.02.06 partially met) The menu and record of food provided must be detailed to indicate there is a choice of meals and snacks which are nutritional, varied and balanced for each service user (timescales of 30.09.05 & 31.01.06 partially met) Any alleged incident of abuse must be immediately reported to CSCI and the Worcestershire adult protection team. Approval of the completion of the alterations to the premises must be obtained from building control and an industry accredited electrician. (timescale of 31/03/06 partially met) 50 of the staff must have an NVQ in care. (timescale of 31.03.06 not met) Timescale for action 31/12/06 2. YA17 17 31/12/06 3. YA23 13 30/09/06 4. YA24 23 31/10/06 5. YA32 18 31/03/07 Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 29 6. YA33 18 7. YA39 24 8. YA42 18,13 9. YA42 24,13,18 10. 11. YA42 YA42 24,13 37 There must be sufficient staff on duty at weekends to support service users with activities in and out of the home A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and all of the aspects of Standard 39. (timescale of 31/03/06 partially met) All staff must have up to date training in safe working practices, specifically administering medication, infection control, moving and handling. The staff must receive training in fire awareness quarterly. (timescale of 31/01/06 partially met) The fire risk assessment must be reviewed. The registered persons must ensure that CSCI are notified, without delay, of any incidents listed in regulation 37. 30/11/06 31/12/06 31/12/06 31/10/06 31/10/06 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The Statement of Purpose needs to be revised and in a suitable format for sending out to interested parties. The updated statement should be available to the service users and their representatives and a copy sent to CSCI. The service user guide should be updated and copies given to service users, their representatives and CSCI. The service user plans should be streamlined and person centred. The arrangements for looking after the service users’ monies should be reviewed to ascertain who could manage DS0000018646.V296883.R01.S.doc Version 5.2 Page 30 2. 3. 4. YA1 YA6 YA7 Dalvington 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. YA7 YA10 YA17 YA19 YA20 YA34 YA35 YA36 YA37 YA42 YA42 YA42 their own monies, with support. The organisation acting as appointee for all service users should be reviewed. All information about service users should be kept in lockable cupboard/cabinets. Consideration should be given to introducing advocates to service users who do not have regular contact with families and friends. Staff should receive training to support the service users in using and keeping up to date the Worcestershire Health Action Plans. The medication policy should be reviewed and include guidance on covert medication and homely remedies. A record of the arrangements for monitoring staff who commence work prior to a CRB check being obtained must be kept. The home should have a training programme based on the in the individual training and development assessments for each member of staff. All staff should have regular, recorded supervision sessions at least six times a year (bi-monthly). The manager should complete training, as agreed at registration. The risk assessments for the premises and safe working practices should be reviewed. The accident book(s) should be in a format that protects the service user’s confidentiality. Consideration should be given to installing thermostatically controlled valves on the washbasins used by service users. Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Dalvington DS0000018646.V296883.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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