Inspection on 18/12/06 for Desmond House Ltd

This inspection was carried out on 18th December 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

Desmond House Ltd 06/06/06

Desmond House Ltd 14/12/05

Desmond House Ltd 19/07/05

Desmond House Ltd 01/03/05

Desmond House Ltd 19/07/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Desmond House Ltd 16-18 Desmond Avenue Hull East Yorkshire HU6 7JZ Lead Inspector Angela Sizer Unannounced Inspection 18 & 22nd December 2006 09:30 th DS0000044243.V322516.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 DS0000044243.V322516.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. DS0000044243.V322516.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Desmond House Ltd Address 16-18 Desmond Avenue Hull East Yorkshire HU6 7JZ 01482 448865 F/P 01482 448865 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) Desmond House Ltd Mr Colin Achmed, Mrs Sharon Achmed Mr Graham Achmed Care Home 19 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (19), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (19) DS0000044243.V322516.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION 1. The registration category MD(E) is to enable service users already resident in the home to remain there upon reaching pensionable age (as long as the The registration category MD(E) is to enable service users already resident in the home to remain there upon reaching pensionable age (as long as the home can continue to meet their needs). Date of last inspection 6th June 2006 Brief Description of the Service: Desmond House is a care home providing accommodation and personal care for 19 persons who have enduring mental health problems. The category for older people is to make sure that individuals can continue to have Desmond House as their permanent home as they approach and pass the age of 65. The care home is privately owned. The accommodation consists of two adjacent semi-detached houses. It is situated close to Beverley Road, a main thoroughfare into the centre of Hull. The home has 13 single and three double rooms, two of the single rooms and one double room have en-suite facilities. There are two lounges and a dining room. There is a garden to the rear and a small parking area. The weekly fees are currently £295.50 - information supplied by G. Achmed on 12.10.06. The registered provider stated that inspection reports are available to the residents and these are displayed on the notice board in the dining room. The Registered Provider also stated that prospective residents are offered a copy of the home’s statement of purpose and service user guide, but there was no evidence to confirm that any of the existing residents had received this information. DS0000044243.V322516.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over two visits and took a total of 9 hours. Prior to the visit surveys were posted out to; 18 residents and 7 were returned, 19 staff members and 2 were returned, 14 health and social care professionals 5 were returned and 9 to general practitioners of which 4 were returned. The majority of the residents were spoken to throughout the day regarding the care they receive and what it is like to live in the home, some of their comments have been included in this report. A visiting relative was spoken to and their views about the home were gained. Three residents’ care records were tracked during the site visit and 2 staff personnel files were looked at. Two of the staff were spoken to find out what it was like working in the home and what training, management and support was offered to them. A tour of the premises was undertaken and a number of records were looked at to ensure that the correct maintenance has been undertaken. The registered manager returned the pre-inspection questionnaire and this gave some details about the service including staffing. From this information the decision was made about which staff and resident files would be looked at. The previous requirements were discussed with the deputy manager and one of the registered providers, approximately two thirds of them have now been met. A discussion occurred regarding how the residents are supported to follow their religion of choice and practise their faith and how the home meets diverse needs of individuals. The registered providers were present throughout the inspection visit and feedback was given at the end of the second visit. The inspector would like to thank the residents, management and staff for welcoming her into the home and contributing to the content of this report. DS0000044243.V322516.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Some documentation has improved since the last inspection including the risk assessment paperwork and care plans. Some parts of the environment have improved. The home has a maintenance plan and budget for the improvements required. The recruitment procedure has been adhered to since the previous inspection, all new employees have the relevant checks in place prior to commencing employment and this ensures the safety of the residents. The home has developed its training plan and individual staff members have a file that clearly details what training has been undertaken and what is outstanding. DS0000044243.V322516.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. DS0000044243.V322516.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 DS0000044243.V322516.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are admitted only on the basis of a full assessment undertaken and the process identifies the needs of the service users. The contract/statement of terms and conditions does specify the services offered and anything that may be outside of the fee. EVIDENCE: As stated in the previous inspection report residents are usually admitted with a full community care assessment and care plan, if this is not available the home undertakes its own assessment, evidence confirming this was seen on care files. One person who had recently come to live in the home spoke about visiting prior to making a decision whether or not to live at Desmond House. They also confirmed that when they had visited both staff and other residents had made them feel welcome. Some comments included; “everyone was really friendly, the staff are smashing and we have a good laugh”, “I came to stay for a meal and then overnight I think before coming to live here”. That resident’s relative was visiting at the time of the inspection and spoke about DS0000044243.V322516.R01.S.doc Version 5.2 Page 10 how her relative was able to visit several homes and that it was their decision what home to go to. Since the last inspection visit the contract/statement of terms and conditons has been amended to include all services offered or excluded. From speaking to the residents it was confirmed that they knew what facilities were included in the fee and what additions they were expected to either contribute to or pay for. As mentioned in previous reports the section about wilful or deliberate damage has been amended and details that any action taken will be discussed and agreed with the resident and/or their representative. Written notes suggested that the home had contacted the care management team re capacity for one resident, but there had been no formal meeting or decision recorded about incidents of damage to the home. DS0000044243.V322516.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has made improvements to the care planning and risk assessment process, this requires further expansion in order to fully meet the needs of the residents and ensure their safety. Residents clearly state that they feel safe and well cared for within the home although some are unable to express their views. Choice is offered to residents. EVIDENCE: A discussion with the two registered providers occurred and an update was given with regard to the ongoing work in relation to the care files, care plans and risk assessment documentation. Three of the residents’ files were looked DS0000044243.V322516.R01.S.doc Version 5.2 Page 12 at and it should be noted that some improvement has been made. The management are currently in the process of updating all care plans, a blank proforma has been developed and this covers a lot of areas including personal details, likes and dislikes, personal care and hygiene, social skills, medication, nutrition and health and safety. Some residents have these new care plans partly completed and these have been carried out in conjunction with the individual residents. The registered providers also explained that they have appointed a new manager and once she commences employment will be auditing all of the systems in place. From speaking to the majority of the residents during the visit it was confirmed that the new care planning system had been discussed with them and they were aware of the content of their own care plan. Some comments included; “I have started my new care plan with my key worker, but it is quite long and will take a long time”, “I know what is in my care plan and I have talked to staff about what I would like putting in it”. From speaking to staff it was clear that they feel more involved in the care planning process, “I have been completing the new care plans with the residents that I am key worker to and I feel that once this is completed we will have a better understanding of the person’s background and history”, “I think it is a really good idea to do the care plans with the residents as they feel involved too”. The risk assessments have improved greatly since the previous visit and from speaking to the Deputy Manager it was obvious that a significant effort has been made in this area. She stated that she had gained risk assessment documentation from various places and has developed appropriate risk paperwork for each resident. Information and advice has also been sought from the Commission for Social Care Inspection. The deputy manager stated, “I think we have greatly improved the paperwork and staff now understand how to use the assessment and do refer to the risk assessments for advice on how to deal with different situations”. “I also recognise that there are further improvements required to ensure that all areas are covered both in the care plans and risk assessments”. The home has made progress with the documentation around care planning, but will need to make further improvements and have a detailed care plan in place for every resident. Prior to the inspection some information was gained from the Commissioning Unit at Hull City Council in relation to the standard of the care and documentation, it was confirmed that since the last inspection visit the home has complied with the council’s requests. From observation and from speaking to the majority of residents it was apparent that overall the residents are enabled to make their own decisions about everyday life within the home. Some of the more able residents are free to and go and the majority lead a fairly independent lifestyle. One resident said, “I go out everyday to the shops, I like to go to the bank”, “I go the community centre and we have a meal and play bingo”. Several residents manage their own finances and one person confirmed, “my money goes into DS0000044243.V322516.R01.S.doc Version 5.2 Page 13 my bank account and I can go and withdraw money whenever I want to. I do let the staff know when I am going out though”. Other residents who are less able and have communication problems do require more support and this was observed to be given in an appropriate way. In the last inspection report it was highlighted that the home had tended to do for rather than with the residents and therefore limiting the choice and autonomy residents have. During this visit it was clear that from observation and from speaking to staff that this area has been addressed in a positive way. One staff member stated, “I have attended a mental health awareness course and feel as though I understand more about our residents who are unable to go out”. Reviews are held on a regular basis and documentation was in place to confirm this. Key workers are now involved in this process and care plans are looked at and updated on a monthly basis. A staff member stated, “I now organise the reviews and feel more involved”. Residents spoken to also confirmed that they have monthly meetings to discuss issues within the home. Some comments included; “We talk about the food and anything else that is bothering us”. There was written evidence that monthly meetings take place for both residents and staff members. It was also confirmed by speaking to the residents that the cook speaks to them on a regular basis to find out what they would like on the menu. Management stated that any changes to the environment, policies and procedures etc are discussed at the residents’ meetings and that residents are consulted to find out their views. DS0000044243.V322516.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. On the whole residents are encouraged to lead an independent lifestyle. Residents are encouraged to take part in appropriate activities both inside and outside of the home. The menu is varied and overall residents are satisfied with the food on offer. EVIDENCE: Prior to the inspection visit-taking place questionnaires were sent out to all of the residents. Seven were returned and all were positive about the level of activities offered within the home. During the inspection several of the residents were spoken to about the range of activities and outings, it was confirmed that since the last inspection visit the activities have increased and DS0000044243.V322516.R01.S.doc Version 5.2 Page 15 the majority of residents now feel happy with what they are offered. One resident spoke about the recent Christmas party, “I enjoyed the Christmas party, there was a buffet and karaoke”. Others stated, “We play bingo twice a week and sometimes we have entertainers come in”. Some of the more able residents go out with the registered provider on a regular basis. One resident commented, “I have been a few times this year to different places, I have been to the seaside and to pub for my dinner”. A visiting relative was spoken to about the level of activities on offer in the home and they commented, “I have seen the staff playing games and bingo with the residents, they also go out quite a lot and I was invited to the Christmas party at a nearby pub”. Other residents informed the inspector that they go to local community centres and day centres on a regular basis. Some comments included; “We have a meal and play bingo, it is nice to see other people”. Several of the residents attend local colleges and community groups and this was confirmed by looking at the case files for individual residents and from speaking to them. During the visit staff were observed interacting with residents and this was carried out in an appropriate manner. All staff spoke to the residents showing respect and called them by the name they prefer. Staff who were spoken to could describe clearly the principles of good care and how they should treat the residents, “with respect, how I would want to be treated by others, respect their privacy and maintain dignity if offering personal care”. A discussion about the diverse needs of individual residents took place with the deputy manager and she described how the home has made a big effort in trying to find out the best way to support less able residents. “Several residents have a learning disability as well as mental health problems and we have been liaising with other professionals involved to find out what activities may be appropriate.” The home is attempting to meet diverse or different needs of the residents and this is promoting inclusion within everyday life in the home. Residents confirmed that they feel they are equal and are treated fairly. The home offers a varied menu, the week’s menu is displayed on the notice board in the dining room. During the inspection visit the residents who were spoken to only had positive comments about the food stating,” the food is very good”, “the cook ask us what we like”. There were no negative comments on the visit to the home. Lunch was observed and consisted of spaghetti or beans on toast, the main meal of the day is served at teatime and consisted of gammon, mashed potato and vegetables followed by chocolate sponge and custard. From speaking to the residents it was confirmed that if there is something that they do not like on the menu then they can have an alternative, “the cook or staff talk to us everyday about what we are having”, evidence of this was recorded in the residents meetings. Breakfast and supper are also offered, there are set times for drinks (hot), staff explained that cold drinks are available throughout the day. Residents confirmed that they “are quite happy” to have drinks at set times. DS0000044243.V322516.R01.S.doc Version 5.2 Page 16 DS0000044243.V322516.R01.S.doc Version 5.2 Page 17 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. Residents physical and emotional needs are overall met. The medication procedure is followed, but residents are not asked or assessed as to the whether they would like to self-medicate. EVIDENCE: During the previous inspection visit two residents commented about not being able to have a bath either everyday or when they wanted to, this is restricting choice and self-determination. There is a bathing rota. The majority of residents did not see this as a problem. During this inspection visit the two residents were spoken again about the bathing issue and it was confirmed that this is no longer a problem. “I understand that I can have a bath whenever I want one, but when I am not feeling well I need some help to make sure that I keep myself clean”, “I have been able to have a bath when I choose to have one, I realise that sometimes I might have to wait a bit for it to be free”. DS0000044243.V322516.R01.S.doc Version 5.2 Page 18 Residents confirmed that they see healthcare professionals including their GP, Community Psychiatric Nurse, District Nurse and Psychiatrist on a regular basis, this was also confirmed from reading the case files. “I go to see my doctor when I need to, sometimes the staff will come with me if I am feeling ill”. The home has a medication procedure and on the whole is adhered to, from inspecting the medication administration records it was evident that the home is now carrying forward any “to be given as required” medication and therefore there is a clear audit trail in place to check that records tally with the stock of medication. The recording and stock control was of a good standard, no errors were found. None of the residents have been assessed as to whether they could self-medicate nor have they been asked if they wish to. One person selfadministers a indigestion liquid. The manager and senior carers who administer medication have undergone medication training with the pharmacy, the manager did not know whether this was accredited or not. Lloyds the pharmacist are currently not visiting the home to audit the medication due to issues with the local Primary Care Trust. DS0000044243.V322516.R01.S.doc Version 5.2 Page 19 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 home has a complaints procedure that enables residents to express their concerns/complaints, this requires further development to incorporate any investigation and action taken. The residents’ protection is not always safeguarded, specifically regarding the restraint policy and the reporting of incidents. EVIDENCE: The home has a complaints procedure, this was displayed in the dining room. From speaking to several of the residents it was clear that they were aware of what they would need to do in order to make a complaint. All but one of the surveys returned from the residents confirmed that they knew the home had a complaints procedure, one person said they did not know about it, but during the site visit this was discussed with them and they confirmed that if they had a problem they could go to the management and that they had misunderstood the question. The home has had several complaints since the last inspection visit and although these are recorded on individual resident files they are not recorded in a central place, so it was difficult to audit the complaints system and it wasn’t always clear about whether an investigation had taken place or if any action was required and what the outcome was. DS0000044243.V322516.R01.S.doc Version 5.2 Page 20 The home has a copy of the multi-agency Protection of Vulnerable Adults procedure and from speaking to two staff members and management it was confirmed that all staff have undertaken the protection of vulnerable adults training. Staff could describe what constituted abuse and what the procedure was if they suspected any abuse was occurring. One staff member said, “It has helped me identify how vulnerable residents are, all of our residents are vulnerable and we need to be aware of what can happen to people”. There have been several incidents with two residents that have resulted in vulnerable adults referrals being made to the local Care Management Team and although these are ongoing, the home took appropriate action at the time and recorded all events thoroughly. There was one incident recorded in the accident book indicating that a resident had slapped another resident and although this was recorded it was not reported to the CSCI as required under regulation 37 nor to the Care Management Team. From speaking to one of the Registered Providers it appears that this incident had been a minor one and a decision had been discussed and was made to record as an accident as there were no injuries to any of the parties involved and both residents had agreed that this was a mis-understanding. DS0000044243.V322516.R01.S.doc Version 5.2 Page 21 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): 24,27 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although improvements to the décor have been made, there are some areas of the environment that requires further attention, as these do not fully meet the residents’ needs. The home is clean and there are no offensive smells, residents live in a clean and warm environment. EVIDENCE: A tour of the premises was undertaken and further improvements have been made since the last inspection visit. The carpets in the dining room, lounge and small non-smoking lounge have been replaced; some of the resident’s bedrooms have been redecorated including bedroom 2 which also has had a DS0000044243.V322516.R01.S.doc Version 5.2 Page 22 new carpet fitted and bedroom 7, which has been redecorated, and the carpet shampooed. The home has undertaken an audit of the building in order to prioritise what areas require updating and renewal. From speaking to the Registered Providers it was clear that they have focused upon the requirements made at the last inspection visit and confirmed verbally that all requirements will be met over the coming year. The home has two bathrooms one downstairs and one upstairs, the water temperature was tested this was 40.5 and 46.8 degrees centigrade and although there are temperature control valves in place the temperature of the water varies and this must be distributed as close to 43 degrees centigrade as possible. The lock on the bathroom door has been renewed and was working properly. Toilet 13 the handle and the lock were not working correctly and require making secure to ensure the privacy and dignity of the residents. Bathroom 12 requires renewal as the grey suite is old and tired looking. The toilet/shower room (20) situated near to the office requires a secure door fitting, the existing one is a flimsy folding door that does not lock and does not ensure the privacy of it’s occupant. The home has now employed a handyman for 16 hours per week and is currently working through the audit of bedrooms and communal areas that require redecoration. During the tour of the premises several residents were spoken to in their bedrooms and their views gained about the environment; “I choose to spend a lot of time in my room and I like it the way it is thank you”, “I like my room and I have got my own things in here, my photographs and ornaments from my mother’s house”, “staff always knock before they come in”. There were no offensive smells present and the home was clean and hygienic. The domestic staff work very hard to maintain these standards and from speaking to staff it was confirmed that the hours for cleaning are in addition to the actual care hours. Staff have received infection control training and were observed to carry out safe working practices using the appropriate equipment that has been put in place since the last inspection. One staff member who undertakes domestic and care duties was spoken to confirming that training is offered, “I have done the vulnerable adults training, NVQ level 2, first aid and I am booked on to do Control of Substances Hazardous to Health (COSHH) in January 2007. I feel more experienced when dealing with residents, the training has been very good”. The home has a dedicated laundry room, which contains an industrial washer and dryer, there is a separate hand washing and a sluice facility. DS0000044243.V322516.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent and qualified staff. The home does not have staffing levels, which ensure that the broad spectrum of residents needs are fully met. Residents are protected by the home’s recruitment policy and practices. Staff receive informal support from management, but formal supervision remains inconsistent. EVIDENCE: Out of the 16 staff members 12 have achieved NVQ level 2, this now exceeds the minimum requirement of 50 . The staff and management have worked very hard to achieve this target and from speaking to some staff members it is clear that they feel valued. Some comments included; “I have done lots of DS0000044243.V322516.R01.S.doc Version 5.2 Page 24 training since the last inspection including mental health, vulnerable adults, medication, first aid, infection control and moving and handling, this has helped me feel more confident and I feel valued now”. This means that the residents are supported by well-trained staff that have a good understanding of their needs. Since the last inspection visit the home has maintained it’s staffing levels to two care workers on duty at all times. The manager’s hours are divided and currently 2 days are spent in a caring role and 3 days in the office attending to management procedures. Discussion with residents, staff and management confirmed that overall the staffing levels are sufficient in meeting basic care needs. Some comments from residents included; “We have more going on now, but sometimes it would be nice to go out with staff”. It would appear that general care needs are met, but other activities do not always occur and this is dependent upon the staffing levels. The recommendation remains for the staffing levels to be critically examined with a view to enable the manager’s hours to be in addition to care hours and therefore giving the time required to focus upon managing and administration of the home. The staffing level is that agreed by the previous regulating authority and under current protocols the home is not required to meet the current standard. A recommendation is made that the staffing levels be reviewed with a view to making the manager’s hours supernumerary, that is separate from the staff time for the direct delivery of care. During the last inspection visit an official letter was issued with regard to the home not undertaking appropriate employment and Criminal Records Bureau checks before employment commenced. Since the last inspection the home has been in regular contact with the CSCI in order to discuss individual cases. The home has adhered to the recruitment procedure and not employed anyone prior to the references and Criminal Records Bureau check being in place. Since the last inspection visit the staff files have been re-organised and training is recorded in individual files. The files were well organised and up to date; it was easy to find evidence confirming that training had been undertaken. All of the mandatory training including health and safety, first aid, food hygiene, protection of vulnerable adults, infection control, fire safety and moving and handling were all either up to date or planned. One staff member spoken to confirmed that the training had been positive, “I feel more confident and I know the other staff do because of the training we have been able to do this year”, “I have done so much training this year, but have found it really good”, “We have several residents who require extra support and one person has a learning disability, I think we now understand how to help them more and offer activities that are appropriate to them”. DS0000044243.V322516.R01.S.doc Version 5.2 Page 25 From speaking to staff it was confirmed that they are offered informal support whenever they need this, but formal supervision is not offered as regular as it should be. One of the staff surveys returned also stated that supervision was not offered on a regular basis. A discussion with the deputy manager highlighted that this had been recognised by management, but currently the home is awaiting the new manager to commence employment and once they commence employment supervision is high priority to organise and implement. The deputy manager stated; “I have been trying to get the supervision in place for everyone, but there was so much to do. Some of the staff have now received formal supervision. This was confirmed when looking at the written records held in the home. DS0000044243.V322516.R01.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents do not always benefit from how the home is run, although they confirm that they are happy with the conduct of the management and staff. The quality assurance system is not effective nor does it seek the views of all stakeholders. Overall the safety of the residents is maintained. EVIDENCE: DS0000044243.V322516.R01.S.doc Version 5.2 Page 27 A discussion occurred with one of the Registered Providers and they explained that the existing manager had decided to hand in his notice. He has agreed to remain in the home until the new manager has commenced employment, which is imminent. Residents were spoken to about the changes occurring and some comments included; “I will miss Graham he has been very helpful to me over the years”, “I have met the new manager and she seems nice, but we will all miss Graham a lot”. Residents did confirm that the current manager and the co-owners were available at any time and also that they were “open and approachable”. The quality assurance system is basic and evidence seen consisted of residents’ and staff meetings, some questionnaires had been given to residents but, there was no evidence that staff or other stakeholders had completed questionnaires. The system requires attention and must include the views of all people who live, work and visit the home, an annual report should be prepared and shared with the residents and other relevant parties including a copy to be forwarded to the CSCI. The Registered Provider explained that the system is currently being looked at by an outside company and will be completed in the near future. The health and safety of the residents is safeguarded and the training in relation to the mandatory training is now offered within six months of employment commencing. From speaking to staff it was evident that the training has improved vastly over the past six months and staff feel more confident in carrying out their duties. Some of the training sessions have included the residents for example the fire safety and the vulnerable adults training. One person said, “I thought it was very helpful, I know why I shouldn’t smoke in my room now”. The home has a fire risk assessment and this was last reviewed on 18.7.06. Smoking in bedrooms continues to be identified as a risk, but measures are in place to minimise the risk such as glass ashtrays, metal bins and the staff monitoring on a regular basis. Accident records are kept, but as mentioned earlier in the report any accident that causes a resident to sustain an injury or affects their well-being must be reported to the CSCI under regulation 37 or protection of vulnerable adult referrals made to the Local Authority’s appropriate Care Management Team. Other maintenance records were looked at including a report confirming that the water had been tested on 22.02.06 for Legionella. Certificates confirming the safety of the gas and electrical wiring were also in place. The fire alarm had been maintained correctly. Regulation 26 visits are not currently being undertaken, the Registered Provider stated that “once the new manager commences employment these visits will commence again and a report will be sent to the commission”. DS0000044243.V322516.R01.S.doc Version 5.2 Page 28 Feedback was give to the Registered Providers at the end of the inspection visits. DS0000044243.V322516.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 1 X 2 X X 2 x DS0000044243.V322516.R01.S.doc Version 5.2 Page 30 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 15,17 Requirement The registered person must ensure that the care plans give detail of all needs and direction to care staff on how to implement these. (Previous timescale 14/03/06 & 6/10/06 - not met) The registered person to further develop the existing risk assessment in order to include all aspects contained within the assessment of need. (Previous timescale 14/03/06 - not met) Timescale for action 22/03/07 2 YA9 12,13,17 22/03/07 3 YA20 12,13,16,17 4 YA22 5 YA23 The registered person must 22/03/07 ensure that all residents are assessed as to whether they can self-medicate within a risk assessment framework. 17,22 The registered person must 22/03/07 ensure that all complaints are recorded and written records are kept in a central place. Details of any investigation, outcome or action required are also recorded. 12,13,16,17,37 All incidents that affect the 22/03/07 DS0000044243.V322516.R01.S.doc Version 5.2 Page 31 6 YA24 23 well being of any resident must be recorded and passed onto the appropriate authority CSCI or Social Services. The registered person must ensure that the home is maintained in a comfortable and homely way. Some bedrooms and the bathrooms/doors require redecoration and renewal. Toilet 13 requires handle repairing or replacing, Toilet 20 door requires replacement with secure lock, Bathroom 12 requires renewal and redecoration. (Previous timescale 14/06/06 & 6/12/06 not met) The registered person must ensure that the upstairs bathroom water temperature is regulated as near to 43 degrees centigrade as possible. The registered person must ensure that supervision with staff is undertaken at least 6 times per year and is recorded. (Previous timescale 14/03/06 & 6/10/06 not met) The registered manager should have achieved NVQ level 4 in both Care and Management by the end of December 2005. 22/06/07 7 YA27 23 22/03/07 8 YA36 12,13,17,18 22/03/07 9 YA37 9 22/06/07 DS0000044243.V322516.R01.S.doc Version 5.2 Page 32 10 YA39 17,24 11 YA42 The registered person must ensure that there is a quality assurance system in place that seeks the views of all stakeholders including residents, relatives, other professionals and staff. Evidence of which must be held within the home and any corrective actions detailed. 12,13,16,17,37 The registered person must ensure that all accident records are correctly recorded and assistance sought from health care professionals as appropriate. (Previous timescale 6/10/06 – not met) 22/06/07 22/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA33 Good Practice Recommendations The registered person should review the homes staffing level in the light of the changing needs of service users and also with a view to the manager’s hours becoming supernumerary. DS0000044243.V322516.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000044243.V322516.R01.S.doc Version 5.2 Page 34 - 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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