Inspection on 27/03/07 for Durham Street and Endymion Street

This inspection was carried out on 27th March 2007.

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

The inspector found 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 12 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 24/10/06

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 27th March 2007 09:30 DS0000065657.V333524.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.V333524.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.V333524.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 vacant post Care Home 7 Category(ies) of Learning disability (7) registration, with number of places DS0000065657.V333524.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th October 2006 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. Since the previous inspection the house at 43a Durham Street has closed and has been deregistered with the CSCI. DS0000065657.V333524.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection and the unannounced site visit took place over 1 day in March 2007. No relatives’ surveys were returned, no service user surveys were returned, and 6 staff surveys were returned. During the visit the inspector spoke to the registered manager, staff and some of the service users to find out how the home was run and if the people who lived there were receiving the right care to meet their needs. In addition to this comments from relatives and observations of care practice have been used to help to form a view whether service users needs are met or not. The inspector looked around the home and looked at records. Information received by the CSCI since the previous inspection was also considered in forming a judgement. Prior to the visit the inspector referred to complaints received and notifications sent to the Commission for Social Care Inspection, the event history for the home over the past year and the completed pre- inspection questionnaire. The site visit was led by Regulation Inspector Mrs.C.Bettison and the visit lasted seven hours. What the service does well: Service users and their relatives are provided with information that is easy to read so that they know what to expect from the home. All service users have an assessment that has been done by a qualified person and this means that the staff know what needs to be in their individual service user plan and can meet all of their needs. Service users are helped to enjoy activities that they like, both in the house and out in the community, this means have an interesting life and do not get bored. All service users have a single room that is nicely personalised to their own taste, providing them with an area where they can spend private time or receive visitors. Relatives are very involved in the home and in general are made to feel welcome, making sure that family can keep in contact. The houses that service users live in are safe, well decorated and kept maintained so that they are comfortable and homely for the service users that live there. DS0000065657.V333524.R01.S.doc Version 5.2 Page 6 The kitchens are kept clean and service users are helped to eat a healthy diet and also some foods that they like. Service users and their relatives concerns are listened to and staff make sure they take action to sort problems out quickly. The staff are very caring and treat service users with respect and dignity. Training has been provided to all staff to make sure all staff are up to date with basic training in moving and assisting, basic first aid, basic food hygiene, infection control and fire awareness. The staff and managers know that they need to make sure service users are protected from harm and what to do if someone is harmed. A good recruitment policy is in place so that staff employed are safe to work with the service users and they are protected from harm. More than half of the staff have got a certificate (NVQ Level 2) which says they know how to work with the service users in the home and how to meet their needs. What has improved since the last inspection? The managers and staff are making good progress to improve all of the standards in the home. Some of the service users had a detailed individual service user plan to make sure they get the care and support they need. The service user plans include helping people to keep their independence and learn new skills. Some of the service users have a health action plan which helps to make sure that their health needs are met. Service users health needs are generally met by a range of professional people. Service users medicines are looked after well and staff assist service users to take their medicines safely. The equipment in the houses and particularly in the bathrooms now meets service users individual needs and helps them to live a more independent lifestyle. DS0000065657.V333524.R01.S.doc Version 5.2 Page 7 A new manager has been brought in to help the staff team and all of the staff vacancies have been filled, this is helping to raise standards of care in the home. 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. DS0000065657.V333524.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.V333524.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 and 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The needs assessments means that people’s individual needs are identified and are able to be met and the home has a service user guide in an accessible format so that service users and their representative have information about what is provided in the home. EVIDENCE: DS0000065657.V333524.R01.S.doc Version 5.2 Page 10 A service user guide has been developed and produced in a format that is accessible to service users and meets Regulation 5 and NMS 1.2. There had been no new admissions to the home since the previous inspection however service users whose care files were examined each had a full needs assessment and care plan completed by the funding authority. There has been an ongoing issue of compatibility between two service users in one of the houses, this is now been addressed with series of meetings being held with the funding authority, health professionals, relatives and advocates and staff from the home to plan for the future. One of the service users informed the inspector that he was planning to move out of the home and get a flat, he was happy about this and said it was what he wanted. The manager needs to ensure that these plans are progressed in a timely manner so that both service users rights are respected and their wishes and choices taken into account. DS0000065657.V333524.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 and 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users individual needs are in general met and this is supported by the development of detailed individual service users plans, health action plans and risk assessments however outcomes for all service users will be improved upon when all service users have these plans in place. EVIDENCE: Three service user care files were examined as part of this site visit. At the previous random inspection it was noted that significant improvements had been made in the development of the service user plans and detailed personalised risk assessments. At this inspection it was noted that further improvements had been made to the majority of care files however not all have been completed yet and this needs to be actioned with some urgency. DS0000065657.V333524.R01.S.doc Version 5.2 Page 12 The care files had been tidied and duplicated documents had been removed leading to clearer direction for staff however there were still some inconsistencies in the quality of the information and recording. Some of the service user plans contained areas for service users to improve their independence skills. For example one service user is being assisted to plan for a move into semi independent living in flat of his own, whilst another was being helped to develop coping strategies for managing his own behaviour and therefore was much more settled in his home and in his life. Care files included management plans where service users display behaviours that may pose a risk to themselves or others, so that staff can provide a consistent approach. However the manager informed the inspector that he had set up a behaviour management programme with one of the service users that may have been construed as being punitive (the health worker had stated this in the minutes of a meeting) and denying the service users his rights. Whilst this was meant to be in the best interests of the service user any limitations on facilities, choice or human rights must be made in partnership by holding a multi agency meeting which includes the service user in the decision making process and minutes of the meeting are retained to evidence all agreements. There was evidence that all service users are helped to choose their own clothes and on the whole make choices about how to spend their time. Two of the service user plans had been clearly written; detailing directions for staff and had been evaluated regularly whilst the other did not have a detailed plan, health action plan and very little other supporting documentation. There was evidence that the service users needs had been reviewed regularly using the Social Services “Fair Access to Care” review system, care programme approach and Avocets own review system. There had been significant improvement made in the recording of discussions and action to be taken in all reviews and that all parties views had been recorded. All but one of the reviews evidenced that the funding authority were satisfied with the service being provided and that the service users range of needs were being met. For the other there has been an ongoing issue of compatibility between two service users in one of the houses, this is now been addressed with series of meetings being held with the funding authority, health professionals, relatives and advocates and staff from the home to plan for the future. One of the service users informed the inspector that he was planning to move out of the home and get a flat; he was happy about this and said it was what he wanted. DS0000065657.V333524.R01.S.doc Version 5.2 Page 13 There were risk assessment tools for a range of activities that posed a risk and included; moving and assisting, bowling, cinema, swimming, fire, visitors, burns and scalds, and environmental issues. DS0000065657.V333524.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): 12,13,15,16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a 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: There was evidence in most of the care files that service users needs/likes/dislikes in respect of activities and lifestyle had been identified and recorded. Religion had been recorded and whether the service user is practising or not. DS0000065657.V333524.R01.S.doc Version 5.2 Page 15 Risk assessments were in place for activities that posed a risk to service users. Observation indicated that staff interact well with the service users, there was a friendly and relaxed rapport in all of the houses during the course of the inspection. Most of the service users were out for part of the day; others were in enjoying the garden. Bedrooms contained a range of personal entertainment items; TV, music 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 and service users and examination of records 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 regularly visits his girlfriend that lives in another residential home and the staff accompanies the service user. Activity plans and records indicated that service users enjoy a range of activities that meet their individual needs and likes;- shopping, cinema, bowling, horse riding, attending avocets five senses day service, watching TV/DVD,s, listening to music, visiting relatives, attending social events, attending college and going to the pub and out for lunch. The manager said he was aiming to develop more activities on an evening and weekends. The staff and service users currently do all of the meal preparation together where possible; the kitchens were clean, tidy and well stocked, and in part have been refurbished 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. Because of a recurring cough and vomiting one of the service users had been assessed by the speech and language therapist and recommendations for a different diet put in place (this had been incorporated into the service user plan and health action plan), which the staff had followed. This has resulted in the service user health and well being improving and as a result the cough and vomiting had stopped and he has put on 6lb since August 2006. 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.V333524.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users health needs are generally met however the incomplete health action plans and recording means that some health and well being concerns may sometimes be overlooked leading to health needs not being fully met. EVIDENCE: There has been significant improvement in the development of health action plans and attention by staff to ensuring that service users health needs are identified, planned for and met. The home has worked in partnership with health colleagues in facilitating the development of health action plans for some of the service users. There are still some to complete but those seen in the course of the site visit were very detailed, up to date and covered all of the service users health needs. The remaining plans must be prepared and implemented with some urgency. DS0000065657.V333524.R01.S.doc Version 5.2 Page 17 However there was evidence in the files of regular appointments/assessments with the GP, consultants, specialist epilepsy nurse, dentist, chiropody, OT, speech and language therapist, physiotherapist and dietician. Because of a recurring cough and vomiting one of the service users had been assessed by the speech and language therapist and recommendations for a different diet put in place (this had been incorporated into the service user plan and health action plan) which the staff had followed. This has resulted in the service user health and well being improving and as a result the cough and vomiting had stopped and he has put on 6lb since August 2006. However it was identified that staff would benefit from some specific training in how to assist service users with eating and swallowing, this has yet to be provided. Two service users that were having difficulty getting in and out of the bath have been assessed by the OT and two bath aids have been provided to ensure that their independence in this area in maintained. Medication systems were examined and Avocet trust have a range of policies and procedures, which ensures that staff had the necessary guidance. Protocols were in place for the administration of PRN medication. Storage of all medications was found to be satisfactory; medications were stored appropriately and stock control was effective. However the staff are transcribing from the medication bottles/packets onto the Medication Administration Record chart and these are not being completed in full. This could lead to staff not being able to follow all of the instructions and service being placed at risk of harm. In addition to this although some staff had completed medication training there as no evidence that an assessment of their competence had been undertaken and this must be addressed. DS0000065657.V333524.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 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 satisfactory complaints system. Service users and their representatives are listened to and their concerns responded to. On the whole service users are protected from abuse whilst in the care home however the incompatibility of two service users compromises their safety and does not protect them from harm. EVIDENCE: The home has a formal complaints procedure provided by Avocet Trust. Complaints are being logged and records kept of all action taken to resolve issues. There had been two complaints to the home since the previous inspection. From the care files examined it was evident that service users that self harm or display behaviours that are difficult to manage now have behaviour management guidelines. Any restrictions or limitations to service users are documented in the form of a service user plan or behaviour management plan, however the manager must provide evidence that these have been agreed by a multi agency team. DS0000065657.V333524.R01.S.doc Version 5.2 Page 19 The home has policies and procedures to cover safeguarding adults and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of service users money and financial affairs. From discussion with staff and staff training records it was evident that most of the staff including the manager and staff have received training or briefing on the Protection Of Vulnerable Adults Policies and Procedures and their responsibilities within this. There had been one new referral to the Protection of Vulnerable Adults team since the previous inspection regarding the ongoing issue of compatibility between two service users in one of the houses, this is now been addressed with series of meetings being held with the funding authority, health professionals, relatives and advocates and staff from the home to plan for the future. One of the service users informed the inspector that he was planning to move out of the home and get a flat, he was happy about this and said it was what he wanted. The manager needs to ensure that these plans are progressed in a timely manner so that both service users rights are respected and their wishes and choices taken into account. DS0000065657.V333524.R01.S.doc Version 5.2 Page 20 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, 28, 29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The environment provides service users with safe, homely and comfortable surroundings, in which to live, which meets service users individual needs. EVIDENCE: 48 Endymion St is owned by Avocet Trust and 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. The houses were clean and tidy and reasonably well decorated, they have all been redecorated in parts and as such are looking cleaner and brighter. The kitchens have been partially refurbished with new worktops fitted and new drawer and door fronts DS0000065657.V333524.R01.S.doc Version 5.2 Page 21 fitted. However Sanctuary Housing has completed this to a poor standard, as the new fronts do not match the existing cupboard fronts. At the previous key inspection staff alerted the inspector to the fact that some service user were a little unsteady on their feet and may benefit for grab rails in the home especially in the bathroom. Following an OT assessment grab rails have been fitted in specific areas of the house to aid service users mobility and independence. At the previous inspection a service user had been observed using someone else’s wheelchair and in addition to this staff were not promoting their independence. This has been addressed and the following an assessment the service user has purchased his own wheelchair and it is only used in the event of inclement weather (windy) as he is unsteady on his feet. The office that was in the living room at the previous inspection has now been moved back into the sleep in room ensuring that service users are able to fully use the living room and that confidentiality is maintained. 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. Avocet trust must undertake a consultation exercise with the staff that sleep in to ascertain if they are satisfied with the sleeping in arrangements and respond appropriately to any issues raised. DS0000065657.V333524.R01.S.doc Version 5.2 Page 22 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 and 36 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The current staffing arrangements are sufficient to meet the needs of the service users and the home is showing much improvement. The plans to consolidate a permanent, consistent and stable staff team will further improve the outcomes for people using the service. EVIDENCE: At the previous inspection there had been a lot of staff changes and the inspector was informed that since then there have been further staff changes. The home has 19 care staff in total;51 Durham St There have been 4 staff leave, 1 dismissed, 1 to take up other employment and 1 moved to another service within Avocet trust and the other transferred to 48 Endymion st DS0000065657.V333524.R01.S.doc Version 5.2 Page 23 2 male staff have transferred from another service to this house and 1 female staff newly recruited and 1 female staff transferred from 48 Endymion st. 49 Durham St 1 member of staff is on long term sick and is covered by either existing staff or bank staff; there have been no other staff changes in this house. 53 Durham St There have been no staff changes in this house. 48 Endymion St There have been 2 staff leave, 1 to take up other employment and 1 transferred to 51 Durham St. 2 staff have transferred from other Avocet trust services. This means that the service is now fully staffed and needs a period of stability to enable staff and service users to get to know each other. Previous inspections evidenced that 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. Significant improvements have been made with regard to the management of the staff team. The manager has undertaken a range of audits and checks to ascertain the baseline of training and what needs to be achieved. The majority of staff have now had an individual training and development assessment and most of the staff are now up to date with mandatory training, which includes infection control and POVA. However it was identified by the speech and langue therapist that staff would benefit from some specific training in how to assist service users with eating and swallowing, this has yet to be provided. 10 of the staff have achieved NVQ level 2 or above which meets the requirement of 50 . Although the manager informed the inspector that all staff have completed the medication training, unfortunately there has been problems obtaining the certificates form the LA to evidence completion of the training, if these cannot be obtained then the manager must undertake an assessment of staffs DS0000065657.V333524.R01.S.doc Version 5.2 Page 24 competence and provide evidence that staff are competent in the safe handling of medication and thereby service users are protected from harm. One new member of staff to the team has completed LDAF induction, however two more new staff have not been registered for it yet; this remains an outstanding requirement and must be actioned. The manager still needs to provide a training plan for the home. Supervision is still of concern both the quantity and quality of supervision. 6 staff files were examined; 1 member of staff had had 6 sessions since September 2006 and 1 had had 5 sessions since October 2006 however 1 member of staff had only had 3 sessions since February 2006, and 3 others had only had 3 sessions since June 2006. The quality of these supervisions was poor as there was very little information recorded and little evidence that staff were being offered individual support and supervision in how to carry out their jobs effectively and meet the needs of service users. However there had been a number of staff meetings held that were detailed and evidenced staff being given instruction in how to provide care and raise the standards in the home and staff spoken to commented that they felt supported and that standards were improving. DS0000065657.V333524.R01.S.doc Version 5.2 Page 25 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): 37,39,40 and 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service users are now receiving a service that is safe and their overall needs are being met, the home is being well managed and showing significant signs of improvement. 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 a service manager. DS0000065657.V333524.R01.S.doc Version 5.2 Page 26 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. The manager of the service – Carl Ince has been transferred from another service within Avocet Trust and has been at the service since December 2006. He informed the inspector that he had a lot of work to do to bring the service up to standard. Carl has worked for Avocet Trust since 1998 and has a number of years of management experience and has achieved the NVQ level 4 in care and management. He has yet to be registered with the CSCI for this service. Policies and procedures have all been reviewed and amended and now meet the requirements. The manager and staff group have made very good progress towards raising the standard of care and supporting documentation in the home, this now needs to be sustained and further developed to ensure that service users needs continue to be met. There have been significant improvements made in the development of care plans, health action plans and risk assessments, stability and support of the staff team and the environment both in terms of its function and appearance. The gas safety certificates were up to date, there was a fire risk assessment and the fire equipment had been checked and there were records of fire drills being undertaken. The electrical hard had been tested and there was also evidence supplied that the home was free of the legionella bacteria. Avocet have developed a QA procedure, which is in the process of being implemented, the implementation timetable for 2007 is as follows; January- Managers away day, training and issuing of files February – staff teams undertake self assessment At this point Stakeholder, client and staff questionnaires will be distributed. March- Analysis by Safety and Quality Manager April- 5x visits by review team May- 5x visits by review team June- Findings and action plan devised Avocet have developed a set of standards for the self assessment tool which include;- Staffing, Environment, Client activities, Facilities, Choice, involvement and feedback, Medication administration, Finance and Belongings, Menus and diet, Health and safety, Care Planning, Policies and procedures and service compliance. The self assessment part of the procedure has been completed and areas for improvement noted as individual service users plans, staff training and staff DS0000065657.V333524.R01.S.doc Version 5.2 Page 27 appraisals to be completed. This system now needs to continue in its implementation and be embedded into the service and a useful tool for identifying and taking action to improve the service. The inspector discussed service users finances with the manager and was informed that as a result of the new Money Laundering Act that The Finance director for Avocet trust had stated that all service users had had to move their bank accounts. He informed the inspector that he had monitored this closely and it had been a relatively smooth operation for the service users at Durham St and Endymion St. He had found some discrepancies in the payments of benefits which he had taken steps to rectify with the benefits agency. There had been no bank charges incurred for these service users as a result of this transfer. As part of the inspection all of the maintenance certificates were seen and were up to date. Staff were up to date with their mandatory training. DS0000065657.V333524.R01.S.doc Version 5.2 Page 28 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 3 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 x 32 2 33 3 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 2 x 2 3 x 2 x DS0000065657.V333524.R01.S.doc Version 5.2 Page 29 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 Requirement Timescale for action 30/06/07 2 YA7 15 3 YA19 13 (1) 4 YA20 13 (2)18 (1) 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, 31/12/06, 28/02/07 and 31/1/07 not met) The registered person must 30/06/07 ensure that any limitations on facilities, choice or human rights are made in the person best interests and are agreed at a multi agency meeting. The registered person must 30/06/07 ensure that Health screening is undertaken and health action plans prepared and implemented for all service users in partnership with the health authority. (Timescale of 31/01/07 not met) The registered person must 30/06/07 ensure that all staff who handle medication have completed the medication training that includes a competency check. (Timescale of 31/01/07 not met) DS0000065657.V333524.R01.S.doc Version 5.2 Page 30 5 YA23 13 (6) 6. YA28 23 7. YA32 18 (1) 8 YA35 18 (1) 9 YA36 18 (2) 10 YA35 18 (1) 11 YA37 9 12 YA39 24 The registered person must ensure that the issue of compatibility between service users is appropriately addressed and service users are protected from harm The registered person must provide staff with adequate and safe sleeping facilities when sleeping in and must consult the staff team and implement action required. (Timescales of 3/12/03, 3/8/04, 31/5/05, 31/12/05 and 31/01/07 not met). The registered person must ensure that all new staff receive both in house induction and induction training that meets LDAF standards. (Timescale of 03/10/05 and 31/01/07 not met) The registered person must ensure that service specific training is provided that enables staff to meet the assessed needs of service users. 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 and 31/03/07 not met) The registered person must ensure that a training plan is developed for the home. (Timescale of 31/01/07 not met) The registered person must ensure that the home is managed effectively. Policies and procedures are implemented and that compliance with the care standards act, regulations and other legal requirements are adhered to. The registered person must DS0000065657.V333524.R01.S.doc 30/06/07 30/06/07 30/06/07 30/06/07 30/06/07 30/06/07 30/06/07 30/06/07 Page 31 Version 5.2 further implement the quality assurance system into the home to takes into account the views of service users and stakeholders. 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.V333524.R01.S.doc Version 5.2 Page 32 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. 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