Inspection on 29/01/08 for Daneswood

This inspection was carried out on 29th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Daneswood 23/10/06

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Daneswood Cuck Hill Shipham Somerset BS25 1RD Lead Inspector Sally Murphy Unannounced Inspection 29th January 2008 11:00 Daneswood DS0000064546.V356758.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 Daneswood DS0000064546.V356758.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. Daneswood DS0000064546.V356758.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Daneswood Address Cuck Hill Shipham Somerset BS25 1RD 01934 843000 01934 843006 Jerry@daneswood.org www.daneswood.org Appleford School Ltd 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) Mr Jeremy Brown Care Home 11 Category(ies) of Learning disability (11), Physical disability (11), registration, with number Sensory impairment (11) of places Daneswood DS0000064546.V356758.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users requiring the use of a wheelchair can only be accommodated in bedroom nos. 1, 2, 3, or 4. 23rd October 2006 Date of last inspection Brief Description of the Service: Daneswood is a large detached property located in the village of Shipham, near Cheddar, Somerset. The service was first registered with the Commission for Social Care Inspection (CSCI) on the 14th June 2006. The home is registered to provide personal care for up to 11 people who have a learning disability, physical disability or sensory impairment. The Registered Manager is Mr Jerry Brown and the Registered Provider is Appleford School Ltd. The home is located in an elevated position with outstanding countryside views. There is a steep winding driveway up to the home. All bedrooms are single occupancy and have en-suite facilities. The bedrooms are arranged over two floors and there is a passenger lift to available. There are a number of communal areas and conservatory areas that offer lounge, dining and recreational facilities. The home also has an indoor hot tub. All areas of the home are maintained and decorated to a good standard. Fees range between £1772.23 – 2859.60 per week dependent upon individuals’ needs. Daneswood DS0000064546.V356758.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this key inspection was to inspect relevant key standards under the Commission for Social Care Inspections ‘Inspecting for Better lives Framework. This focuses on outcomes for residents and measures the quality the service under for general headings. These are; excellent, good, adequate and poor. The inspection took place over the course of one-day in January 2008, by one inspector (7 hrs). An expert by experience completed part of this inspection. An ‘expert by experience’ is a person who because of their shared experience of using services, and/or ways of communicating visits a service with a inspector to help them get a picture of what it is like to live in or use the service. The expert by experience provided some verbal feedback on the day of inspection and written feedback following the visit. Information received from the ‘expert by experience’ has been included in this report within the section relating to Lifestyle and Environment. The home completed an Annual Quality Assurance Assessment (AQAA) and surveys were sent out to residents, relatives, staff, GPs and health and social care professionals. The results of surveys are incorporated into the report. During the course of the inspection discussions were held with the Registered Manager and Provider, and staff members. Records were examined relating to people living at the home, staff recruitment and training and health and safety. Care practice was observed and a tour of the premises made. There were 11 people living at the home and one person receiving day care on the day of the inspection. The home has applied to CSCI to increase the registration of the home to provide care for up to 17 people. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: The home completes a comprehensive assessment of need and liaises closely with staff involved in peoples care to ensure that they have the appropriate skills, and knowledge to meet peoples needs. Daneswood DS0000064546.V356758.R01.S.doc Version 5.2 Page 6 Care plans provided appropriate guidance to staff on how to support people. These included detailed plans relating to the provision of personal care, morning routine and daily activities. Within the surveys received relatives stated that ‘we are free to visit whenever and are made to feel very welcome’ and that the ‘day to day care is excellent’. A homeopathic consultant visits the home each month and prescribes medication for the people living there. The home has an appropriate and detailed policy regarding the protection of vulnerable adults and clear directions to staff on the actions to be taken. The home also has appropraite policies regarding whistleblowing, managing aggression, physical intervention and gifts. Daneswood provides a spacious and comfortable environment. There are appropriate adaptations to meet peoples’ needs. There is a good range of communal areas. Bedrooms have been decorated and furnished to reflect individuals’ tastes and preferences. Staffing levels offer a high level of support to people at the home. The home operates a robust recruitment procedure that protects people living there. Staff are well supported and receive regular supervision. The management team are experienced and have the necessary skills and knowledge to undertake their role. What has improved since the last inspection? Staff who administer medication have been provided with appropriate training, and an assessment of competency completed prior to them giving medication within the home. Since the last inspection the Deputy Manager has been appointed. He is a qualified Nurse for people who have a learning disability and brings further skills and experience to the home. Staff have continued to complete assessments and assist people in moving into the home. Some people have begun attending college. The home has applied to CSCI to increase the registration of the home to proivde care for up to 17 people. A soft play room and sensory room will be included within the new development. Daneswood DS0000064546.V356758.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. Daneswood DS0000064546.V356758.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 Daneswood DS0000064546.V356758.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): 1,2,3 & 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their families are provided with appropriate information to make an informed choice regarding admission to the home. A comprehensive assessment of need is completed prior to people moving into ensure the home will be able to fully meet their needs. EVIDENCE: The home has produced a Statement of Purpose and Service User Guide that gives information on the range of services and facilities provided. The home is currently undertaking work to produce the Service User Guide in a format that is accessible for those people living at the home. Information regarding the complaints procedure should be updated in both documents to state that CSCI may be contacted at any stage. The home has an admissions procedure. Pre-admission assessments were seen within care plans. The home liaises closely with staff involved in peoples care to ensure that they have the appropriate skills, and knowledge to meet peoples needs. Within the AQAA it states that ‘in some cases staff from Daneswood have spent up to 3 months working with a young person before they moved in’. Daneswood DS0000064546.V356758.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): 7,8,9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans provide appropriate guidance to staff how to assist each person in meeting their needs. People living at the home are supported to exercise choice. Information is stored securely and confidences maintained. EVIDENCE: Care plans are maintained for each person living at the home. Four care plans were examined in detail during this inspection. It was found that each contained a photograph of the person. There were detailed plans relating to the provision of personal care, morning routine and daily activities. A behavioural plan was in place for one person. This had been signed by their key worker, the Registered Manager, and a Chartered Psychologist, (who is also the Registered Provider for the home). The Social Worker for this person should also be consulted regarding the development of these plans. Daneswood DS0000064546.V356758.R01.S.doc Version 5.2 Page 11 Each person living at the home receives 1:1 support from staff members. Staff confirmed that they receive comprehensive information regarding each person before they commence working with them. The home operates a key worker scheme. Staff demonstrated a good knowledge of people’s needs and preferences. People are supported to exercise choice over they life and daily activities. Where people have limited communication staff seek their views though observing their reactions and non-verbal communication. Communication passports had been completed for some people. During the course of the inspection people were observed moving freely around the home and gardens, and spending time within their bedroom or communal areas, as they prefer. People are encouraged to participate in the running of the home as is appropriate to their level of ability and preferences, for example through taking items to the laundry. Individual risk assessments had been completed for people living at the home and the activities that they choose to participate in. Staff at the home are not appointee for anyone, however they do assist people in managing their personal monies. Records had been maintained of all transactions involving people finances. These had been supported by staff signatures and receipts. The home has a confidentiality policy. All records relating to people living at the home had been stored securely and were up to date. Daneswood DS0000064546.V356758.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): 11,12,13,14,15,16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to participate in a range of activities. They are supported to maintain contact with family members and access the local community. Staff have a good knowledge of individuals’ dietary needs and preferences. People living at the home are provided with nutritious and well-balanced meals. EVIDENCE: Within the information provided to CSCI prior to the inspection it states that ‘We provide our young people with a healthy lifestyle with an organic wholefood diet. The young people participate in a wide range of activites both on and off site. All the young peole here go out to access a range of community activities, some attend college courses’. Daneswood DS0000064546.V356758.R01.S.doc Version 5.2 Page 13 The ‘expert by experience’ focussed upon the activities and choices available to people at the home. They found that four people attend college. They stated that people ‘have music therapy and an hour to relax each day called ‘rest hour’. They also go ‘swimming, horse riding and use the hydrotherapy pool at the home’. Two people were observed making valentine cards. Discussions were also held regarding trips to the nearby towns of Cheddar and Weston, going bowling and attending a club in Weston. The ‘expert by experience’ wrote that ’the staff plan with the residents their activities customised for each individual’ and that ‘the staff gauge if they like where and what they are doing by their reactions’. People are supported to maintain links with families. One person goes home every weekend. The ‘expert by experience’ stated that ‘staff are respectful to residents’, but commented sometimes they observed people being spoken to like children rather than young adults. This was fedback to the Registered Manager at the close of the inspection. They explained that many of the people had recently moved from a residential school and that work was taking place with staff to develop the culture of an adult service. Within the surveys received from relatives one person wrote that the ‘integration, personal care, socializing’ were good, whilst another stated that there could be ‘more activities and books in the lounge area’. All of the relatives who completed surveys stated that they are ‘always’, or ‘usually’ kept up to date. Meals are prepared on the premises. The home has recently employed a Cook. All produce is organic. The Cook has a good knowledge of peoples’ individual dietary needs. A number of people at the home have specialist diets, requiring the preparation of several different meals. One person has a separate diet that is prepared by their key worker. There was a range of desserts available to meet people’s needs and preferences. One of the people living at the home is Japanese. The home has liaised with their family and previous carers and sought to prepare some Japanese dishes. Staff have recently introduced two sittings at meal times to allow people who require assistance more time, and a quieter environment to enjoy their food. Staff spoken with stated that this change was positive. There was evidence that staff were aware of individuals dietary needs, and were taking action to address these. Daneswood DS0000064546.V356758.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 adequate. This judgement has been made using available evidence including a visit to this service. People receive appropriate support to meet their personal care needs. Failure to complete nutritional risk assessments and moving and handling assessments may mean that staff do not have the appropriate information to fully and safely meet people’s needs. People may be placed at risk through failure to complete medication records appropriately, and through failure to store oxygen cylinders securely. EVIDENCE: Care plans include detailed guidance regarding the provision of personal care. The home has a policy regarding intimate and personal care. This states that personal care should be provided by a member of the same gender wherever possible. All rooms have en suite facilities. The home has appropriate policies promoting the dignity and privacy of people at the home. Daneswood DS0000064546.V356758.R01.S.doc Version 5.2 Page 15 Care records evidenced that actions were taken to address people’s health needs. Records had been maintained of all professional visits. Within the records for some people it stated that they might be at risk of losing weight. There were instructions to staff to offer snacks in between meals and to weigh the person regularly, however a nutritional risk assessment had not been completed. Following the inspection these were undertaken and a copy forwarded to CSCI. Weekly food charts had been completed for one person, but were not dated so it was not possible to determine which period these related to. Moving and handing asssessments had not been completed for some people. This included people who use wheelchairs. These too have subsequently been completed and forwarded to CSCI. The home must ensure that these are completed for all people living at the home, and that they are reivewed regularly. The home has a detailed medication policy. This includes information on homeopathic and homely remedies. During the inspection it was identified that this policy did not include information on invasive techniques such as the rectal administration of medication. The policy has subsequently been amended and a copy forwarded to CSCI. Medication is stored securely. Medication Administration Records (MARs) were examined. It was found that there was no record of the quantity received, date or staff signature for some medication. There were also two gaps in medication records were staff had not recorded a signature that the medication was given or a definition as appropriate. It is good practice for hand written entries to be checked as correct and signed by a second staff member to reduce the risk of error. An immediate requirement was issued in relation to these matters. The Registered Manager has provided written confirmation that these issues have been addressed individually with staff and that medication records are now being checked at the end of each shift. It was also noted that an opening date had not been recorded for eye drops. This is important to ensure that medication is not used after 28 days of opening. Oxygen cylinders had been stored in the medication room and one person’s room. Oxygen cylinders must be secured to the wall or a trolley to ensure that they cannot fall over and cause injury. There must also be appropriate signage displayed on the doors of rooms where oxygen is kept. Following the inspection the Registered Manager has forwarded a copy of the fire risk assessment to CSCI, to demonstrate that this has been updated appropriately to reflect the storage of oxygen within the building. There are appropriate protocols in place regarding the administration of epilepsy medication. The home was provided with further guidance regarding the storage of controlled drugs. Daneswood DS0000064546.V356758.R01.S.doc Version 5.2 Page 16 A homeopathic consultant visits the home each month and prescribes medication for the people living there. Staff who administer medication have been provided with appropriate training, and an assessment of competency completed prior to them giving medication within the home. Daneswood DS0000064546.V356758.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): 22 & 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints policy and recording system must be further developed to ensure that people are listened to and their views acted upon. The home has appropriate policies in place to protect people. EVIDENCE: The home has a complaints procedure. Following the inspection this has been updated to state that CSCI may be contacted at any stage. Within the surveys received from relatives it was evident that some concerns / complaints had been raised however these had not been recorded within the complaints log. This was disucssed with the Regsitered Manager during the inspection. These matters must be recorded to evidence the actions being taken by the home to listen to, and act upon peoples views. Within the survyes received from relatives, all but one of the respondents stated that they knew how to make a complaint. The home has an appropriate and detailed policy regarding the protection of vulnerable adults and clear directions to staff on the actions to be taken. The home also has appropriate policies regarding whistleblowing, managing aggression, physical intervention and gifts. Daneswood DS0000064546.V356758.R01.S.doc Version 5.2 Page 18 For the protection of vulnerable people the home ensures that appropriate information is obtained regarding staff members prior to them commencing work at the home. Daneswood DS0000064546.V356758.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): 24,25,26,27,28 & 29. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a spacious and comfortable environment. There are appropriate adaptations to meet peoples’ needs. There is a good range of communal areas. Bedrooms have been decorated and furnished to reflect individuals’ tastes and preferences. The home has generally been maintained to a good standard of cleanliness, however some areas require further attention to ensure that all parts of the home remain clean and hygienic. EVIDENCE: Daneswood is a large detached property situated in a rural setting close to the town of Cheddar. The home is accessed via a steep winding driveway. There are a range of communal areas available including two conservatives, lounge and dining areas. There is a hydrotherapy pool on the ground floor and a large assisted bathroom on the first floor. Daneswood DS0000064546.V356758.R01.S.doc Version 5.2 Page 20 Rooms within the home are spacious and have been decorated and furnished to a good standard. The home is set within large grounds. The ‘expert by experience’ stated that ‘the home is nicely decorated and spacious’ and that there is ‘plenty of space for 1:1 work’. Bedrooms are single occupancy and all have en suite facilities. Bedrooms have been decorated and furnished to reflect individuals’ tastes and preferences. There are appropriate adaptations available within the home to meet the individual and collective needs of people living there. The home plans to install a call system that will incorporate an electronic pad situated underneath peoples mattresses to monitor their breathing and heart trace. This is intended to provide further monitoring for people who have epilepsy and complex health needs. During a tour of the premises it was noted that there was an unrestricted window in one person’ s room and that paintwork needed repair around the hand wash in another person en suite bathroom. Some paintwork around the home had become damaged and required repair as part of the general programme of redecoration within the home. Due to problems with the lift not working one person whose bedroom is on the first floor has been sleeping in a dining area. CSCI had not been informed of this. Notifications have subsequently been completed, and it is intended that this person will return to using their room as soon as the lift is mended. Generally the standard of clenaliness thorughout the home was good. However the floor within the hydrotherapy room was dirty and there were some cobwebs. The overhead hoist in this room was dusty. The laundry is well organised, and washing machines have a sluice facility. Due to items being moved within the laundry the water proof flooring does not cover the whole area. Damage to plasterwork must also be repaired to ensure that the area may be kept clean and hygenic. Appropriate handwashing facilities had been provided for staff. A foot operated flip top bin must be provided to reduce the risk of cross infection. Red alginate bags are available. The home has applied to CSCI to increase the registration of the home to proivde care for up to 17 people. A soft play room and sensory room will be included as part of the new development. Daneswood DS0000064546.V356758.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): 31,32,33,34,35 & 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels offer a high level of support to people at the home. Staff require updates in mandatory training to ensure that they are able to look after people safely. The home operates a robust recruitment procedure that protects people living at the home. Staff are well supported and receive regular supervision. EVIDENCE: All of the people living at Daneswood receive 1:1 support from staff throughout the day. There are three staff on duty during the night, including one person who provides 1:1 to one person. Copies of duty rotas were provided. These evidenced that these staffing levels are maintained. A cook, domestic and maintenance staff are also employed. Daneswood DS0000064546.V356758.R01.S.doc Version 5.2 Page 22 Within the surveys received from staff members 4 out of the 6 respondents stated that there is not always a senior member of staff on duty to confer with. The Registered Manager advised that this is being discussed with the Directors of the home. Due to the complex needs of the people living at Daneswood, it is recommended that there is always a senior member of staff on duty, and that the person leading the shift is highlighted on the duty rota. Within the surveys staff were asked ‘Do you ever have to deal with situations you feel unprepared for or do not have the right training for? To which 3 answered ‘yes’ and 3 ‘no’. Comments received within the surveys received from relatives indicated that most staff had the skills and experience to meet peoples’ needs but that a number of staff were new and were undergoing training. Recruitment records were examined for four staff members. It was found that each contained a completed application form, two references, health declaration, POVA first check and enhanced CRB disclosure. The application form had been updated to state that the post was exempt from the Rehabilitation of Offenders Act, and gaps in employment had been explored and recorded. Staff had been provided with a job description, and an interview record had been maintained. All newly appointed staff had completed induction training. A copy of the staff training matrix was provided. This evidenced that a number of staff require updates in mandatory training such as fire safety, manual handling, first aid and health and safety. Due to the needs of the people living at the home all staff must be provided with manual handling training as a priority. The home should also seek to ensure that staff have received training on the ‘role of a care worker’, ‘abuse’ and ‘raising concerns’ and the Mental Capacity Act 2005. This document states that 18 out of the 41 care staff employed have completed NVQ 2 or an equivalent qualification and that a further 8 are studying for the NVQ 2 qualification and 6 towards NVQ Level 3. Within the documentation provided to CSCI the home has advised that further training in planned on: fire prevention, fire drills and evacuation, food hygiene, harmony and natural rhythms, Somerset Total Communication, infection control and effective communication. Supervision records had been maintained. It was evident that where there had been concerns raised regarding any staff members conduct that these had been fully investigated and followed up appropriately. 5 out of 6 staff that returned surveys confirmed that they receive regular supervision. Daneswood DS0000064546.V356758.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): 37,38,39,40,41 & 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management team are experienced and have the necessary skills and knowledge to undertake their role. Equipment has not been appropriately maintained to ensure the health and safety of people and staff at the home. EVIDENCE: The Registered Manager is Jeremy Brown. He is an experienced manager and has many years experience of providing care to people who have a disability. Since the last inspection the Deputy Manager has been appointed. He is a qualified Nurse for people who have a learning disability and brings further skills and experience to the home. Daneswood DS0000064546.V356758.R01.S.doc Version 5.2 Page 24 The Registered Manager advised that surveys are issued to parents, social workers and others involved in people’s care on an annual basis. These were last issued during May 2007 and the outcomes from these passed to the senior management team to shape and improve the service. The home displays Employers liability insurance. Many of the policies and procedures are dated June / July 2006 and require review to ensure that they continue to reflect best practice. The Registered Provider had completed visits to the home on a monthly basis. Fire safety records were examined. It was found that equipment had been serviced and tested as required, and that records had been maintained of fire drills. As previously stated (under Staffing) records evidenced that some staff required updates in fire safety training. During the course of the inspection the Inspector was advised that the passenger lift had not been working since October 2007. A risk assessment had been put in place, which stated that people who use wheelchairs are taken outside the building and use the slope to access the upper floor. However due to poor weather conditions the common practice was for two staff to use the evacuation chair to take someone upstairs. Accident records indicated that there had been two accidents to people living at the home and one staff member as a result of the lift being out of action. These matters were discussed at the inspection. A general risk assessment regarding the lift and individual moving and handling risk assessments have been updated and copies forwarded to the Inspector. CSCI had not been notified of the lift being out of action. This has subsequently been completed, and the home has obtained guidance on the incidents that need to be notified to CSCI in accordance with Regulation 37 of the Care Home Regulations 2001. Records relating to the electrical hardwiring, portable appliances, and sit on scales had been appropriately maintained. Gas appliances were last tested on 06/1/06 and must be completed on an annual basis. Lifting equipment had not been tested on a six monthly basis, in accordance with LOLER regulations 1998. The Registered Manager has subsequently provided copies of certificates to CSCI to evidence that this has been completed. There were on-going problems with the hoist in the hydrotherapy room, which were being investigated. Within the small kitchen there was a layer of grease and food debris at the base of the units and edges of the floor. These must be thoroughly cleaned. Within the large kitchen there are plans to replace an area of units and flooring, with new appliances and equipment that can be easily cleaned. Daneswood DS0000064546.V356758.R01.S.doc Version 5.2 Page 25 All foods stored within fridges and freezers had been covered and dated and daily temperatures recorded. The home has obtained new COSSH sheets. All hazardous substances had been stored securely and were not accessible to people living at the home. Daneswood DS0000064546.V356758.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 2 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 2 27 3 28 4 29 3 30 2 STAFFING Standard No Score 31 3 32 2 33 2 34 3 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 1 X 3 3 3 2 3 1 3 Daneswood DS0000064546.V356758.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 YA18 Regulation 17 & schedule 3 (3) [m] Requirement Nutritional assessments and moving and handling assessment must be completed for each person and reviewed on a regular basis. Where a high level of risk is identified an appropriate plan must be put in place to address this. 2. YA20 13 (2) An appropriate record must be maintained for all medication received into the home. The record must include a staff signature, date and quantity. Immediate requirement: timescale 29/1/08 An opening date must be recorded for eye drops. 3. YA20 13 (4) [c] 29/02/08 Timescale for action 14/03/08 Oxygen cylinders must be 21/03/08 secured to the wall or a trolley to ensure that they cannot fall over and cause injury. There must also be appropriate signage displayed on the doors of rooms where oxygen is kept. DS0000064546.V356758.R01.S.doc Version 5.2 Page 28 Daneswood 4. 5. YA22 YA26 22 (7) & (8) 13 (4) [a] A complaints log must be maintained. A risk assessment must be completed in relation to the unrestricted window within one persons’ bedroom and any appropriate actions taken. The paintwork around the hand basin in another persons’ room requires repair. 29/02/08 14/03/08 6. YA30 23 (2) [d] & 13 (3) The hydrotherapy room must be kept clean. A foot operated flip top bin must be provided to reduce the risk of cross infection. 29/02/08 7. YA30 13 (3) Waterproof flooring must be provided for the whole of the laundry and areas of plasterwork repaired to ensure that the area may be kept clean and hygienic. Staff require updates in mandatory training such as fire safety, manual handling, first aid and health and safety. Due to the needs of the people living at the home all staff must be provided with manual handling training as a priority. 28/03/08 8. YA35 18 (1) [c] (i) 11/04/08 9. YA40 24 (1) Many of the policies and procedures are dated June / July 2006 and require review to ensure that they continue to reflect best practice. The passenger lift must be repaired and a notification sent to CSCI when this is completed. The hoist within the 11/04/08 10. YA42 13 (5) 14/03/08 Daneswood DS0000064546.V356758.R01.S.doc Version 5.2 Page 29 hydrotherapy room must be in working order. 11. 12. YA42 YA42 13 (4) [c] 23 (2) [d] Gas appliances must be tested on an annual basis. 14/03/08 The base of cupboards within the 29/02/08 small kitchen must be thoroughly cleaned. Some equipment and flooring within the large kitchen must be replaced to ensure that the kitchen remains clean and hygienic. 11/04/08 13. YA42 23 (2) [d] 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 Registered Manager should consider producing the Statement of Purpose and Service User Guide in a more accessible format such as symbols and photographs. Where a behavioural plan is developed this should be discussed and signed by the Social Worker for this person. ‘ The Registered Manager should ensure that all hand transcribed medicines and remedies are supported by two staff signatures. The complaints procedure should be reviewed to state that people may contact CSCI at any time. (This includes reference to the complaints procedure within the Statement of Purpose and Service User Guide). Staff should receive training on the ‘role of a care worker’, ‘abuse’ and ‘raising concerns’ and the Mental Capacity Act 2005. 2. 3. YA9 YA20 4. YA22 5. YA32 Daneswood DS0000064546.V356758.R01.S.doc Version 5.2 Page 30 6. YA33 Due to the complex needs of the people living at Daneswood, it is recommended that there is always a senior member of staff on duty, and that the person leading the shift is highlighted on the duty rota. Daneswood DS0000064546.V356758.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection South West Regional Office 4th Floor, 33 Colston Avenue Colston 33 BS1 4UA Bristol 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 Daneswood DS0000064546.V356758.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. 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