Inspection on 24/10/06 for Durham Street and Endymion Street

This inspection was carried out on 24th October 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 28 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Durham Street and Endymion Street 03/03/09

Durham Street and Endymion Street 13/03/08

Durham Street and Endymion Street 27/03/07

Durham Street and Endymion Street 03/10/05

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Durham Street and Endymion Street 49 51 & 53 Durham Street Hull East Yorkshire HU8 8RF Lead Inspector Christina Bettison Unannounced Inspection 24 October 2006 09:30 th DS0000065657.V308015.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 DS0000065657.V308015.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. DS0000065657.V308015.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Durham Street and Endymion Street Address 49 51 & 53 Durham Street Hull East Yorkshire HU8 8RF 01482 223324 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) Avocet Trust Undergoing Registration Process Care Home 8 Category(ies) of Learning disability (8) registration, with number of places DS0000065657.V308015.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd October 2005 Brief Description of the Service: The service at 49-53 Durham Street is managed by Avocet Trust who rent the premises from Sanctuary Housing Association. It is one of a small number of similar services that Avocet provides. Avocet Trust is a registered charity. 4953 Durham Street is registered to provide care and accommodation for up to 5 adults with a learning disability. The home is off Holderness Road to the east of the city centre. 49-53 Durham Street consists of three separate living units. No. 49 is a ground floor flat for one person, with a bedroom, living room, kitchen, bathroom and rear garden. Nos. 51 and 53 have similar facilities with an additional single bedroom each and are for two adults. No. 51 is at ground floor level. No. 53 is above it, accessed by an internal staircase with own front door. The properties adjoin each other and share a large communal garden at the front. There is parking available on the street. 48 Endymion St is a terraced property for two people owned and managed by Avocet trust. The house consists of a small hall, lounge, dining room, kitchen and utility room, and two bedrooms with en-suite facilities. There are a variety of shops, pubs, and health facilities nearby. Public transport to various parts of the city is accessible and in addition service users have access to cars arranged through their mobility benefits. Weekly fees are approximately per person per week. Additional charges are made for the following: newspapers/magazines, hairdressing, chiropody, transport for social activities and sweets. Information on the service is made available to current service users via the statement of purpose, service user guide and inspection report. DS0000065657.V308015.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector visited the home for one day in October 2006; we didn’t tell anyone that she would be coming. The inspector was called Tina Bettison and she was at the home for 7 hours. We sent out some comment cards before the inspection and 4 service users replied, 2 Relative’s replied; 2 health and social care professionals replied and 10 staff replied. During the visit Tina (the inspector) spoke to 4 service users, the manager and some staff, to find out how the home was run and if the people who lived there were getting good care. Relatives told us “ …is far happier at Durham St than he ever was and seems very content”, and “The organisation has continually struggled with staffing. ………….thrives on consistency but staff changes are numerous and unacceptable there have been occasions when the home has struggled to provide staff cover” The inspector looked around the home and looked at some records. Before the visit the inspector looked at information sent to the Commission for Social Care Inspection. What the service does well: Avocet Trust provides houses and personal care support for adults with a learning disability and other needs. The main aim is to help people to develop and keep as much independence as possible, whilst helping them to be more confident and live in the community. The people and their families/advocates are given enough information about the home to help them to make a choice about whether the home will be good for them or not. The houses are in the local community and are on a bus route making all leisure facilities and shops easy to get to. Each person living in the home has a single room that meets their needs, in a house alone or with one other person providing them with some shared space and private space. Families are made to feel welcome when visiting their relative. DS0000065657.V308015.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: People that are new to the home must be given the opportunity to test it out before moving in and choose who they are going to live with, staff and social workers must think about whether this choice will work or not. Each person living in the home should have a service users plan that clearly says what staff need to do to meet all of their needs. Some of the people living in the home do not have a plan; this means that their needs may not be met. When the people living at the home do activities and behave in a way that could be dangerous to themselves and/or others there should be a plan and a risk assessment to tell staff what to do to protect all of the people living at the home. Some of the people living at the home did not have such a plan so everyone is not protected from harm. Each person living at the home should have a plan that sets out what professional people like doctors and nurses need to do to make sure that they are kept in good health, this has not happened for everyone and means that their health needs may not be met. Staff in the home must make sure that they look after and give people their medication safely and keep a record of this. They all need some training to help them to do this better. All of the staff need some training in how to protect people who live in the home from harm. The kitchens in the houses are very old and need to be repaired or replaced to make sure that people live in a house that is safe, clean and looks nice. When the people that live in the house have special needs or need equipment to help them get around, this equipment must be provided. The manager needs to prepare a plan of training for the staff and all staff need to have all of the training to help them do their job properly. DS0000065657.V308015.R01.S.doc Version 5.2 Page 7 The training must include infection control and medication training and some special training, all of this will lead to service users needs being met and them being protected from harm. Each member of staff at the home should have a regular meeting with the manager to discuss the training they may need, support and other things. This has not been happening as often as it should. The home needs a manager that is good at their job to make sure the home is run properly, that peoples needs are met and the home is safe for the people that live there. A quality monitoring system must be introduced to make sure that everyone is asked about the running of the home and improvements are made. The Commission for Social Care Inspection is worried about the management and standards of care in the home. The standards at the home have got worse since the last inspection and people that live in the home may not be getting a good service. 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. DS0000065657.V308015.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 DS0000065657.V308015.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users needs were assessed prior to admission and information is available to service users and their relatives to enable them to make an informed choice about whether the home is able to meet their needs or not, however lack of trial visits and compatibility issues means that service users needs and aspirations may not be met. EVIDENCE: There have been two new admissions since the last inspection the homes statement of purpose and service user guide provides service users with details of the services the home provides and enabling them to make an informed decision about admission to the home. Each service user has their own individual care file and all three of those examined in the course of the inspection contained a full needs assessment and updated care plan completed by the funding authority, however one of them did not contain a service users plan, risk assessments and strategies for dealing with difficult behaviour, therefore their needs may not be met and the other two plans needed to be more detailed and accurate for the individual service user. (One of the plans had a different name and related to a different service user in places). DS0000065657.V308015.R01.S.doc Version 5.2 Page 10 For the two recently admitted service users there was no evidence that opportunities for trial visits and overnight stays had been arranged and in addition one of the service users had been placed with a service user with very different needs. This has created some difficulties within this house and both the manager and staff commenting that the match has not been a good one. For the other service user he was able to tell the inspector that he liked living there and that he had helped choosing the colours for his room. A recently held review highlighted that he had settled well. DS0000065657.V308015.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Service users needs are met on an informal basis by staff, the quality of the service user plans and risk assessments is inconsistent and some of them are very basic. These shortfalls have the potential to place people at risk and mean that service users assessed needs are not met. EVIDENCE: Some information is available in care files however it does not reflect the full range of needs and does not ensure that all aspects of health, personal and social care needs are identified and planned for. Three care files were examined as part of the inspection process. In two cases the service user plans did not include everything that is detailed in the local authority assessment/care plan and did not detail accurately what staff need to DS0000065657.V308015.R01.S.doc Version 5.2 Page 12 do to meet service users needs and in the third case the service user did not have a service user plan at all. The quality of information recorded in care files which should include service users plans, reviews, risk assessments and monitoring was inconsistent. This was discussed with the manager and the inspector was informed that it is the senior support workers/grade c workers responsibility to complete this documentation. It was clear from examination of care files and discussion with staff that this was dependent on the skills and motivation of the specific staff in each house. For one care file examined, the LA had reviewed the placement on 8/6/06 and the LA care plan had been updated. The Service user plan/IPP in places had the name of another service user suggesting that another IPP had been used as a template and not a lot of attention had been paid to ensuring that it was accurate and reflected this individual service users need. This service user can at times display behaviour that is difficult to manage and specific techniques are used to manage his behaviour, there was a risk/relapse plan completed by the Health authority in place and there was monitoring of incidents. For another care file examined, the records were very disorganised and it was difficult to track care from the records. There had been a Care Programme Approach review on 1/8/05 but no reviews held since. There was no service user plan to reflect their needs and give staff direction on how to meet these needs. This particular service user is prescribed medication to be administered PRN during periods of aggressive behaviour however there was no protocol in place to instruct staff in what circumstances this medication can be administered. In the third care file examined it contained a service user plan however this could have been more detailed; it had been reviewed on 22/2/06. There were no risk assessments completed for the activities and occasions that may pose a risk to the service user and how these could be minimised and this must be addressed. This particular service is without sight and the manager must ensure that core documents are translated into Braille and or an audio version to enable the service user to have access to his records. Discussion with staff and examination of records indicated that service users basic care needs were being met even though there was a lack of clear plans and guidance and this could not be evidenced in all cases from the records. This approach is dependent on staff memory and good verbal communication systems. Service users are at risk of not having their care needs met if these informal systems break down. Discussion with staff, service users and a visiting relative indicated that service users are able to with support make decisions about their lives and the running of the home. One of the service users was able to tell the inspector how they DS0000065657.V308015.R01.S.doc Version 5.2 Page 13 had been involved in the interviewing for new staff and what role they had played. DS0000065657.V308015.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. A range of activities and opportunities for leisure activities within the home and community mean the service users have the opportunity to participate in stimulating and motivating activities that meet their individual needs, wants and aspirations. EVIDENCE: Observation indicated that staff interact well with the service users, there was a friendly and relaxed rapport in most of the houses during the course of the inspection. Some service users were out for the day, others were in enjoying the garden, watching TV or in their rooms. Two service user showed the inspector their bedrooms where they had a range of personal entertainment items; TV, music DS0000065657.V308015.R01.S.doc Version 5.2 Page 15 systems, and one service user had a record deck and told the inspector that he likes to be a DJ at functions. Discussion with staff, service users and relatives indicates that family and friends are able to visit the home and can use any of the communal facilities or the service users bedroom. There is no restriction on visiting times. Some service users go out to visit their relatives and stay overnight and some service users maintain contact with their relatives via mail and telephone. One of the service users spoken to together with his key worker was able to tell the inspector about his visit to see a Pink Floyd tribute band, his planned visit to the Elvis convention and two holidays that were planned to Centre Parks and Cyprus for next year. He has an activity timetable that includes lots of swimming (which he said he really likes) bowling and horse riding. Other service users access avocets five senses provision and participate in household chores. Another Service user told the inspector that they access a variety of community activities and particularly like shopping at the local charity shops for music CD,s. The staff and service users currently do all of the meal preparation together where possible; the kitchens were clean, tidy and well stocked, however apart from Endymion St they are in need of refurbishment as detailed in the Environment section of this report. The staff promote a healthy eating menu but try to balance this with service users likes/dislikes and special treats on occasions. The menu plan appeared to be well balanced. Breakfast consists of a variety of cereals, fruit, toast, tea, coffee and juice. Lunch is a choice of sandwiches, soup, beans or egg on toast or omelette, jacket potatoes with a choice of fillings. Options on the menu for dinner included chicken, beef, mince, pasta and fish and supper is offered. DS0000065657.V308015.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Service user’s health, personal and social care needs are being met in an informal manner and staff have not received training in medication administration that includes a competency check this gives the potential for areas of need to be missed and service users to be placed at risk of harm. EVIDENCE: There was evidence in the files of appointments/liaison with the GP, consultants, community nurse, dentist, chiropody, and occupational and physiotherapist. However there has been little attention paid to the appropriate planning of health interventions and the quality of recording is inconsistent. There had been no health screening undertaken and there were no health action plans on any of the three care files examined. There appeared to be weight monitoring taking place. The inspector was concerned that one service user period of ill health had not been managed effectively and the records evidencing what action had been taken were poor. The service user had been very sick and had a loss of appetite and the GP had prescribed antibiotics and referred them for a chest xDS0000065657.V308015.R01.S.doc Version 5.2 Page 17 ray, which was done on the 14/9/06, and the results would be available in 10 days time. Various medications were tried by the GP with no apparent improvement in the service users condition. The records did not evidence that the results of the X ray had been obtained and what the outcome was. The manager had to ring around the staff to find out that the service user had had some blood tests done and had been referred for an endoscopy on the 17/11/06. There were no written records to support this. This is very poor practice and places service users at the risk of harm if their health needs/concerns are not followed up promptly and action taken to resolve them. Medication systems were examined; policies and procedures were in place however the records supporting the administration of medication was poor. For one service user there was no MAR sheet and the administration had been written on the reverse of an old MAR sheet. Stock control was poor there was no quantities carried over so that the staff and manager had no idea of how much stock they were or should be holding. For some medication the labels on the medication did not match the MAR sheet. There were no protocols in place for the administration of PRN medication. Not all staff have not completed a medication training course that includes a competency check. DS0000065657.V308015.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The home has a complaints system and complaints are handled appropriately, however the lack of service user plans, risk assessments and competency of staff means that service users are not protected from harm whilst in the care home. EVIDENCE: Avocet Trust have a complaints procedure, which appears to have been implemented within the home, there had been no complaints received by the CSCI or the provider since the previous inspection. Avocet Trust has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of service users money and financial affairs. The staff have not yet all had Protection Of Vulnerable Adults (POVA) training. The lack of service user plans, risk assessments, lack of attention to health needs and competency of staff means that service users are not protected from harm whilst in the care home. DS0000065657.V308015.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The environment provides service users with comfortable surroundings in which to live, however the refurbishment of the kitchens and provision of equipment would further enhance the quality of the accommodation. EVIDENCE: 48 Endymion St is a beautifully decorated, safe and comfortable house in which two service users live. It is well maintained, clean and tidy yet had a lived in feel about it. 49-53 Durham St is a property owned by sanctuary housing and has an institutional feel to it. Although the houses were clean and tidy and reasonably well decorated, they did appear a little tired in their appearance. The main areas of concern in the houses are the kitchens, there were doors and drawer fronts missing and in one kitchen the worktop was resting on something and not fixed. The inspector was informed that the kitchens have never been replaced since the home opened and they are now very dated and past their best. DS0000065657.V308015.R01.S.doc Version 5.2 Page 20 In 51 Durham St the living room was also used an office and as such staff were seen to congregate in this area, this encroaches on the service users shared space/living room and is unacceptable practice and must be addressed. During the course of the inspection the inspector met with two visiting physiotherapists who had arrived to assess a service user for a wheelchair. It became apparent during the visit that the staff had been assisting the service user to use someone else’s wheelchair for which he was not assessed. This is dangerous practice and must cease immediately and it does not take into account the promotion of the service users independence skills. The physiotherapist assessed the service user as not needing a wheelchair and suggested that the staff take into account his age and other needs and plan outings accordingly. The manager must ensure that service users independence is promoted and that equipment is not routinely used for service users that do not need it. Staff alerted the inspector to the fact that some service user are a little unsteady on their feet and may benefit for grab rails in the home especially in the bathroom. The manager must ensure that service user individual moving and handling needs are assessed and that the houses are assessed as per the DDA and equipment provided as required. The inspector was informed and observed that there is now a sleeping in room for staff at two of the houses 51 and 53 Durham St however the staff that sleep in at 49 Durham St have to use a pull out bed and sleep in the lounge, this is unacceptable and must be addressed. DS0000065657.V308015.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The current staffing arrangements are sufficient to meet the needs of the service users however both mandatory and specialised training must be provided. Staff are not adequately supervised which may lead to poor care practices and mean that service users are not protected from harm and their needs not met. EVIDENCE: The home has 17 staff in total; information received prior to the inspection indicated that there have been a lot of staff changes. There have been 12 staff leave since the previous inspection and 1 vacant post has been recruited to. 4 of the staff resigned, 6 staff transferred to other services within Avocet Trust and 2 staff were dismissed. The house at 43a Durham Street has closed and is awaiting deregistration so not all of the staff vacancies needed to be recruited to. DS0000065657.V308015.R01.S.doc Version 5.2 Page 22 Recruitment practices have greatly improved; all staff now have 2 written references and CRB clearances prior to commencement this means service users are protected from harm. The inspector was concerned that despite being requirements at the previous inspections the manager still needs to undertake individual training profiles for staff and provide a training plan for the home and ensure that all staff are up to date with mandatory training, to include infection control, POVA and medication training. The manager stated that a number of staff have achieved NVQ level 2 and 3 staff are currently undertaking level 3. There are a further 2 staff currently doing NVQ level 2 and 2 doing NVQ level 4. This is good progress and needs to continue. A member of staff that was new to the home at the previous inspection had commented to the inspector that they had not had any in house induction, from examination of records it was clear that this person had still not any induction and none of the staff (who need it) have been registered on LDAF induction. Supervision is of serious concern both the quantity and quality of supervision. 4 staff files were examined; One of staff had received only one supervision in approximately 18 months, and three staff had had none since commencing at Durham St. This does not meet the requirements and does give staff the support they need to carry out their jobs effectively. DS0000065657.V308015.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The Commission for Social Care Inspection is concerned about the management and standards of care in the home. There has been a significant deterioration in the standards of care and management in the home since the previous inspection EVIDENCE: The organisation has a clear organisational and management structure in place. Dedicated human resource and administration teams, finance section, health and safety and training teams. There is a chief executive and service manager. The organisation is a registered charity and as such is audited by the charity commission, there is a dedicated finance manager and the organisation is financially viable. All insurance cover is in place. DS0000065657.V308015.R01.S.doc Version 5.2 Page 24 Policies and procedures have all been reviewed and amended and now meet the requirements. The inspector was informed that the QA procedure has been developed however there was no evidence that it is being implemented into the home yet and the manager informed the inspector that he didn’t have the file. All records as required by this standard were not available, specifically service user plans and supervision records. The manager of the home informed the inspector that it had been increasingly difficult to undertake all the management tasks associated with running a care home of this size as he is expected to work part of his week on shift. This becomes apparent when taking into account the deterioration in standards in the home. There is a lack of detailed service user plans and guidelines, poor attention to service users health needs, lack of training and lack of supervision of staff. Risk has not been managed effectively and therefore service users are not being protected from harm. Incidences of behaviour management are not being appropriately recorded and monitored and no action has been taken to address this. There were records available to support that electrical installations were safe, however the gas safety certificates were out of date. Water temperatures were being taken and the home had a fire risk assessment. Despite previous concerns raised by CSCI about the poor management of the home, Avocet have failed to take any action. In addition Avocets own monitoring of the running of the home was superficial and failed to explore how the home was truly running and take appropriate action. This is not acceptable. DS0000065657.V308015.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 2 4 2 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 3 29 2 30 3 STAFFING Standard No Score 31 x 32 2 33 2 34 3 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 x 1 x LIFESTYLES Standard No Score 11 x 12 3 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 1 x 1 x 1 3 x 2 x DS0000065657.V308015.R01.S.doc Version 5.2 Page 26 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 YA3 YA4 Regulation 12 14 Requirement The registered person must ensure that new service users are given opportunities to test drive the home and the issues of compatibility between service users are adequately assessed prior to admission. The registered person must ensure that all service users have an individual plan that covers all aspects of personal, social and health needs and that service users independence is promoted. (Timescale of 03/10/05 not met) The registered person must ensure that risk assessments are completed for all activities that may pose a risk to service users and this must include moving and handling risk assessments. The registered person must ensure service users health needs are met and issues /concerns are followed up promptly and accurate records kept. The registered person must ensure that Health screening is undertaken and health action DS0000065657.V308015.R01.S.doc Timescale for action 31/01/07 2. YA6 15 31/12/06 3 YA9 YA42 13 (4) 31/12/06 4 YA19 YA42 13 (1) 31/12/06 5 YA19 13 (1) 31/01/07 Version 5.2 Page 27 6 YA20 YA42 13 (2) 7 YA20 13 (2) 18 (1) 8. YA23 13 (6) 9 YA24 YA42 23 10 YA27 YA42 13 (5) 23 23 11. YA28 12 13. YA32 YA33 18 24 14. YA35 18 (1) plans prepared and implemented in partnership with the health authority. The registered person must ensure that medication policies and procedures are followed for the recording, handling, safekeeping, safe administration and disposal of medication. The registered person must ensure that all staff who handle medication have completed the medication training that includes a competency check. The registered person must ensure that all staff are aware of their responsibilities regarding POVA. Training must be provided. (Timescale of 31/03/06 not met) The registered person must ensure an assessment of the houses in undertaken in relation to the DDA and equipment provided/adaptations made as required. The registered person must ensure that service users moving and handling needs are assessed and equipment provided /adaptations made as required. The registered person must provide staff with adequate and safe sleeping facilities when sleeping in. (Timescales of 3/12/03, 3/8/04, 31/5/05 and 31/12/05 not met). The registered person must ensure that staff perform their duties in a competent manner. The registered person must ensure that staff meetings are undertaken regularly. (Timescale of 03/10/05 not met) The registered person must ensure that all new staff receive both in house induction and induction training that meets DS0000065657.V308015.R01.S.doc 31/12/06 31/12/06 31/01/07 31/01/07 31/12/06 31/01/07 31/01/07 31/12/06 31/01/07 Page 28 Version 5.2 15. YA35 18 (1) 16 17. YA35 YA35 YA42 18 (1) 18 (1) 18. YA36 18 (2) 19 YA37 8 20 YA39 24 21 YA42 23 LDAF standards. (Timescale of 03/10/05 not met) The registered person must ensure that all staff have an individual training profile. (Timescale of 30/9/05 and 31/03/06 not met) The registered person must ensure that a training plan is developed for the home. The registered person must ensure that all staff are up to date with mandatory training and this must include infection control. (Timescale of 31/12/05 not met) The registered person must ensure that all staff receive formal supervision at least 6 times per year and that the quality of this supervision is improved. (Timescale of 03/10/05 not met) The registered person must appoint a manager that is qualified and competent to run the home. The registered person must implement the quality assurance system into the home that takes into account the views of service users and stakeholders. The registered person must ensure that gas safety certificate is obtained. 31/01/07 31/01/07 31/01/07 31/03/07 31/12/06 31/03/07 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000065657.V308015.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000065657.V308015.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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