Inspection on 08/09/08 for Evimiz

This inspection was carried out on 8th September 2008.

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

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

Evimiz 10/09/07

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 23/11/2008.

CARE HOME ADULTS 18-65 Evimiz 155 Fairview Road Cheltenham Gloucestershire GL52 2EX Lead Inspector Mrs Helen James Unannounced Inspection 8th September 2008 09:30 Evimiz DS0000068544.V370008.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 Evimiz DS0000068544.V370008.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. Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Evimiz Address 155 Fairview Road Cheltenham Gloucestershire GL52 2EX 01242 701779 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) david@evimizcare.com Evimizcare.com Evimiz Care Ltd Mr David Paul Dodwell Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - (Code PC) to male service users whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is 3. Date of last inspection 10th September 2007 Brief Description of the Service: Evimiz Care Ltd is a converted domestic dwelling in the centre of the Fairview area of Cheltenham. It is a terraced house that provides residential accommodation for up to three male adults with Learning Disabilities/Autistic Spectrum Disorder from eighteen to sixty-five. The house has accommodation on the ground and first floor. There are three single bedrooms with use of a communal bathroom with bath, hand basin, and toilet and shower cubicle. There are no en-suite facilities in the home. On the ground floor is a communal lounge, dining room and kitchen. Off the kitchen is the laundry area, a toilet and access to the courtyard garden. The Manager/Staff office/sleep-in room is located in the basement. All the accommodation has been registered to meet current environmental standards. To the front of the property is the pavement and on-road parking. The courtyard garden is to the rear of the property and is screened by a fence with access from the street via a locked gate, all of which is adequately maintained at the present time. The fee range for the home is from £1033 to £1220 per week dependent on needs. Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The judgements contained in this report have been made from evidence gathered during the inspection process, which included a visit to the service and takes into account the views and experiences of people using the service. This Key Unannounced Inspection took place over one day in September 2008 and was completed by one inspector. Twenty-six Care Standards for Younger Adults including all twenty-one Key standards were assessed on this occasion. The Annual Quality Assurance Assessment (AQAA) record was completed and returned to the Commission from the Provider prior to the inspection. Surveys were sent to the service for distribution prior to the inspection and three people who live at the home and two staff returned these prior to the inspection. Some of their comments feature in this report. Time during the inspection was spent speaking with the Registered Manager; two care staff and people living at the home to gauge their views and experiences of the service and the care. The opportunities for people to exercise choice and to maintain social contacts were also considered. Checks were made against the statutory requirements issued at the last key inspection, in order to assess the home’s compliance. Time was spent time cross-referencing information about the care and welfare gained from talking to/observing people with individual care records. A sample of other records were examined to include accidents, staff files, staff training logs, quality assurance documentation and health and safety systems. A tour of the premises took place, with particular attention to health and safety issues, maintenance and cleanliness of the premises. What the service does well: Evimiz Care is run in a pleasant non-institutional way with attention being made to make it a family-like atmosphere, whilst ensuring the health and welfare of the individuals who live at the home. The home is in the heart of the community and allows for easy access for people to enjoy a full social life. The staff team appear committed to the philosophy of ensuring that people living at the home engage in a range of social and recreational activities that are age appropriate, improve their quality of life and integrate them in the local community, and they do this well. Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 6 People are admitted to the home on the basis of a comprehensive assessment of their individual needs. Upon admission each person has their own personal documented careplan that addresses their individual needs. People observed appeared comfortable and appropriately cared for, two were able to tell us their experience of living at the home, they spoke positively about the way, in which they were looked after, of nice, helpful staff and good attention. People living at the home indicated that they enjoy the activities and social events with support and that the staff focus on people’s interests and things they enjoy doing. People through surveys conveyed that ‘they were helped by the carers’ and ‘I am never made to do anything I do not want to do’, they also shared that sometimes ‘they need staff to make decisions for them because sometimes they are not able too, it depends how they are feeling’. Relatives from in-house surveys indicated that they felt supported by the home and knew how to complain. One family did feel that communication could be better and this is being addressed. No relative or visitors visited the home during the inspection. The care plan system involves the individual and their families. The care record ensures that all members of staff have a clear understanding of the person centred care each person requires. The care staff appeared to respect peoples’ privacy and encourage, support and promote independence within a risk framework. People told us that they are not restricted in any way in their daily lives. Appropriate support equipment was in use in conjunction with individual risk assessments, there was evidence of appropriate medical reviews and input from appropriate healthcare professionals, and there were examples seen of people receiving good care and support. People are reassured that the home takes any complaints and concerns seriously and does all it can to help them. There are policies and procedures in place for the protection of the vulnerable people, which staff appear familiar with. What has improved since the last inspection? Sixteen of the twenty statutory requirements for improvement issued at the last key inspection had been met. Redecoration and refurbishment is ongoing in order to maintain the environment in good order for the people living here. Management records relating to health and safety issues and regular checks were now in place. There was evidence that if any action had been necessary that it had been completed. Evimiz DS0000068544.V370008.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. Evimiz DS0000068544.V370008.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 Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that each prospective person receives appropriate information to make a choice about living at the home although this needs to be further improved to make it fully accessible for the person requiring care. They receive a full assessment during the process of admission to ensure that all their specific care needs can be met by the Home. EVIDENCE: The statement of purpose and the service users guide are available in the home. The Manager reports that this information is given to individuals/ families/representatives on enquiry/admission. The Manager has started to convert these into formats that can be understood by people using the service, but this still requires further work as; information is missing from the ‘pictorial’ version given to the inspector during the inspection. The written one and pictorial one both need changes to the language used to ensure they are written in ‘plain’ English and accessible those using the service. The Manager has added to the pictorial service user guide about the Fire procedures and the alarm testing in the home but not the written one. Reviews of individuals care are being done regularly and at a minimum yearly with all relevant parties concerned and with the placing Authorities and this are recorded in the care file. Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning system involves the individual, their family and the funding Authority to ensure that everyone has a clear understanding of the personcentred care required to lead a full and rewarding life. Care plans ensure people are treated with respect and dignity and facilitated to live as independent a life as possible within their own limitations. EVIDENCE: Comprehensive information is maintained for people living at the home. This is being regularly monitored, reviewed and updated with the individuals. Two of the three care records of people living at the home were examined. Two people were spoken with during the inspection and one gave limited responses. One person was observed. The records contained all the required documentation and were clear in how the individuals were to be managed regarding their care. Care plans ensure people are treated with respect and dignity and facilitated to live as Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 11 independent a life as possible within their own limitations and risk factors. Where a choice is inappropriate or dangerous staff will give guidance to ensure a positive outcome for the person involved. Care plans and activity plans are discussed with each individual person and where possible signatory evidence on care plans is being sought to demonstrate individual’s / relatives involvement in the preparation of these plans and their agreement. It was evident from the daily notes and observation that staff adhere to risk assessments. People living at the home were seen spoken too, addressed properly, politely and in a dignified manner, all interactions were appropriate. Staff confirmed that they are involved in the reviews of individuals. Any restrictions to choice or freedom are recorded on people’s files. Through discussion with the manager and observations at the home it was evident that choice is promoted fully at the home. One person was seen assisting in home chores, hanging his clothes on the line, putting things away about the home. People seen around the home were in and out of the communal/personal space with no restrictions placed upon them. A full range of risk assessments are in place for a variety of activities both inside and outside the home and several of these were examined and demonstrated enablement within a risk framework. These are signed and regularly reviewed. The following minor amendments to care record must be implemented: • All entries, reviews and amendments must be dated and signed to allow an audit trail of care changes etc. • Where there is a risk assessment about behaviour and action to be taken this must be placed with the daily behaviour recording sheet so that staff know what to do. Under Regulation 37 the home have a legal duty to inform the CSCI of any event/incident that affects the health or wellbeing of an individual within their care so all fits/accidents etc must be notified to the Commission this has not happened in one incident noted in records. People living at the home have choice about their daily routine and are consulted about all aspects of life at the home via informal means at the present time. It is recommended that formal house meetings with minutes be implemented. Individuals’ records are accurate, secure and confidential. Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to participate in age, peer and culturally appropriate activities through engagement in social activities of their choice and liking within the local community. Individuals are offered a healthy diet and are able to participate in the buying and preparation. EVIDENCE: People living at the home have individualised programmes of daytime activities during the week. Entries in the care record are made about the activities that individuals participate in and with whom, giving a valuable insight into the diversity of activities that the individuals’ engage in and demonstrates that not everyone is doing the same thing. It also demonstrates that they are part of the wider Community. Outings are arranged that they like and choose to do. This was evidenced in the records. A daily record is kept of where people are, with whom and when they will return. Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 13 People living at the home are given choice in everything they do and are consulted about what they want to do within the restrictions of their ability and safety. Assistance and supervision for all activities is available at all times and where extra staff is needed they are made available. People at the home are also given the opportunity to go on holiday during the year and are involved in the planning and preparation for this. Pictures were displayed in the dining room of the recent summer holiday that two people went on with staff. The Manager reported that the home has tried set menu plans but this had not met the needs of the residents. Meals are now prepared according to what individuals would like to eat but consideration is given to a healthy balanced diet when doing this. What is eaten is recorded in individual care files daily as this may differ depending on where people are and what activities etc they may be doing. Meal times are very flexible and people do eat out if they are in town or out. The people living at the home are involved in the daily meal planning (discussion about meals heard and observed during the visit). The Manager does the weekly shop with residents if they choose and they can be involved with the cooking with the care staff. Weight monitoring for loss and gain is undertaken and recorded and appropriate action is taken to address any issues raised that may impact on the health of the individual. The kitchen is clean and tidy and a documented cleaning schedule is in place that includes temperatures of the fridge and freezer, cooking temperatures for appropriate foods and a food probe is available. The Manager and staff must maintain comprehensive records in line with ‘Safer Food Safer Business’ guidelines. Environmental Health has visited and there were no issues. All staff has Basic Food Hygiene certificates, which are current. Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The personal needs of people living at the home are supported in the way they prefer and through good multi disciplinary working ensuring all healthcare needs are fully met. People at the present time are not fully protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: People in the home appear to have the freedom of choice around their daily activities within their own limitations and this takes into consideration any individual risk assessment or assistance they may require, as seen in records. The three people living at the home have communication difficulties and the fact that there is small reliable team of staff who are very familiar with individual behaviour and communication ensures that individuals’ needs are met. The staff know through behaviour/ gestures etc when individuals require assistance or need something. It was observed during the visit that communication tools are used when appropriate but a total Communication Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 15 Approach needs to be developed further using a range of objects of reference, pictures, photographs, symbols, gestures etc. Of the two care files examined it was very clearly identified how the individuals were supported in their care plans and personal profiles. There appears to be flexibility in routines dictated by the needs and disposition of the people living at the home. People are referred to the Community Learning Disabilities Team and to the appropriate health and welfare professionals at their request or when it is necessary. It is required that where specific instructions are given for management of individuals that this is documented by the Health Professional in the care file so it acts as a reference for staff. All medical and healthcare visits and checks are clearly recorded and comply with the health checks required by the individual. All equipment needed for residents’ health care is supplied appropriately by the Community Nursing services or the GP. District nurses visits on request and when they need to provide care. Issues relating to life and death wishes have not yet been discussed and documented or signed by the person and/or their next of kin and this must be addressed. People at the home are registered with local GP’s and this is arrangement works well. The GP supplies a prescription for a monthly supply of medication to the local chemist and they provide the home with a weekly Monitored Dose system (MDS) of medication due to storage issues. On examination of the medication system it was apparent that the system is not maintained in compliance with regulations. The following was identified: • The home had Medication Administration Records (MAR) that denoted a 28-day supply had been dispensed and no entry in how many came into the home, so it was impossible to audit the system. • There were no records of amounts of medication ‘into’ or ‘out of’ the home because staff receiving the medication had not been signing it in or out on the MAR chart. • There were two different MAR charts being used. • There were no photos of people with the MAR charts. • There was no list of staff names with signatures. • There was no allergy status completed on the MAR chart. This was discussed with the Manager and he explained that it is dispensed monthly by the GP but sent to the home weekly due to storage issues. It was explained to the Manager that the records from the chemist and in the home must demonstrate this. Guidance was given on what is required with the management of the medication and the necessity for this to be addressed Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 16 immediately within the home and with the Chemist. The Manager was also referred to guidance on the CSCI website. It was also established that there was medication missing from the end of the weeks’ supply. This was due to a resident going on a home visit with the homes’ MDS and MAR chart and the chart coming back but not the MDS pack. There was no system in place for ensuring safety of medication for people when they go on a home visit. The Manager was advised that he must put a system in place and a written policy and procedure, so that this medication is signed in and out of the home. The Manager must implement a regular medication audit. The Manager must arrange ASSET accredited medication training for all staff and ensure that policies and procedures relating to medication practice specific to the home are in place. Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. People are confident in the knowledge that any concerns they may express will be listened to and acted upon. Systems are in place that safeguard people from possible harm or abuse. EVIDENCE: The home or the Commission has received no complaints. The Complaint procedure is explicit in the Statement of purpose for those able to read and understand it, but this must be in a format that is completely accessible to the people living at the home, this needs further development. The Manager has devised and implemented complaint and compliment forms for the service. No concerns or complaints were identified during the recent Quality survey that the Manager sent to relatives and people at the home. It is required that this survey is extended to external stakeholders and Healthcare professionals to seek their views. Certificated evidence was seen that staff have been updated in Adult Protection this year with the new procedures and guidance for the County. The Manager must ensure that all visitors to the home sign into the home, for fire and security purposes. Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical environment provides for the individual requirements of people living at the home. People live in a home that is safe, clean and well maintained that complies with infection control standards. EVIDENCE: A walk around the environment was conducted two personal rooms were seen. Bedrooms are being decorated to individual tastes, individual rooms seen at inspection were personalised with belongings, personal sound and vision equipment, photographs and pictures, giving a homely feel. The communal areas were pleasantly decorated and appeared comfortable. The Manager said that individuals had brought their own furniture and possessions with them and had been involved in the colour schemes etc in their rooms. Equipment for special needs is provided as the need is identified. All the people living at the home will need to be able to walk upstairs as there is no lift or stair lift. Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 19 At the time of the inspection the home was clean and tidy. There was evidence that staff are provided with personal protective equipment that is accessible throughout the home. The laundry room was clean and had washable wall and floor surfaces and hand washing facilities. Domestic washing and drying machines are available. All staff have a responsibility for overseeing the laundry and cleaning within the home this is explicit in the generic support worker job description. People living at the home can assist with washing and drying their clothes and bed linen if they wish, this was observed during the visit and on discussion with one person he really enjoyed doing this. Records of cleaning throughout the home are maintained to ensure standards of cleanliness in the home and for auditing purposes. Hazardous products are locked away and data sheets/risk assessments are kept in the cleaning cupboard in the home, although products used are domestic products. Personal toiletries are kept in individuals’ rooms and taken to the bathroom each time they receive personal care. All staff still have not received infection control training Manager has had difficulty accessing this training. There is a handyman who deals with ‘day-to-day’ maintenance issues and records are kept. No maintenance issues were identified during the inspection. The exterior has been painted and the front low wall has been replaced with low railings and the front garden has been completed. The Manager reported that the window in the rear bedroom is to be completely replaced and will have integral window restrictors. Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 20 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, 34 & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ needs are met by a competent staff team, who have access to a training programmes that ensures that staff have knowledge about the diverse needs of people living at the home. People at the present time protected by recruitment practice at the home but it needs to be totally robust. EVIDENCE: Inspection information seen indicated that the Manager works 9am-5pm each day and is then able to do shifts when there is a shortfall. Two care staff work at the home during the day and at night there is waking night staff and the manager is on–call at all times. This staffing is suitable at the present time to meet the needs of the individuals living at the home. Several staff work on a bank basis so that there can be flexibility of staffing duties depending on what is happening each day. All have been appointed since the home was registered in March 2007. Only one member of staff has been recruited since the last inspection the Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 21 recruitment practice has greatly improved but there was one issue identified that requires addressing to comply with Regulation 19. The file seen: • Did not have a complete Employment history from the time the person left school, this information needs to be completed and documented on the personal file. Staff are now given an induction that complies with the Common Induction Standards and evidence was seen of this and the Manager reports that he sees staff through this and signs it off. Evidence was seen via training records that staff recruited have had mandatory training and specific training since they have been at Evimiz Care and this is ongoing. All staff have received specific training for the client group at the home but one area that still staff need to be trained in is dealing with challenging behaviour and crisis intervention. The Manager has devised a training matrix. The AQAA states that the staff training and development policy outlines the regularity of staff supervision and that staff’s training needs are identified through team meetings and staff supervision. But this cannot be evidenced, as there are no records of these within the home. The Manager states that he is doing these informally, this is not satisfactory and must be addressed, through formalised sessions and written documentation. Training must be well supported by regular supervision sessions (six times a year) and yearly appraisals and these must be recorded to evidence the content of the supervision and staff development. Of the eight care staff four have a National Vocational Training (NVQ) Level 2 or above in health and social care (adults). Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 22 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. People using the service are safeguarded by management that actively promotes their best interests offering them choice, respecting their wishes and keeping them safe. But further safeguards to their health, safety and welfare must be implemented. EVIDENCE: The Manager has an Open University qualification in ‘Managing Health and Social Care’ and is in doing the National Vocational Qualification level 4 in Care. He is actively pursuing his continuing professional development by participation in local training and attending training courses to develop his skills and abilities. The Manager needs to fully understand the legal responsibilities he has under the Care Standards Act and that the onus is on him to read and understand Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 23 guidance for systems within the home and understand the consequences when systems are not rigorous enough. Several issues were highlighted with the Manager from examination of documentation and in discussion that require addressing immediately now the service is providing care to people and employing staff these are discussed throughout the report. The following Policies and Procedures must be fully in place now: - death of service user, Management of service users money, some aspects of the management of medication and any others that the Manager deems as necessary, which are not yet in place. With regard to residents’ personal monies, funds are placed in the Business Account and whilst auditable records are kept, this is not in line with Guidance issued by the Commission and the Manager must endeavour to address this. Ideally, funds must be deposited into named accounts for individuals. The Manager reported that they are in the process of dealing with this issue but have found it difficult with the new measures banks have put in place to open individual accounts. The Manager also reported difficulties with individuals obtaining their personal allowances. The Manager was advised to deal with this through the Social Worker, as this is the residents’ money to spend on things that improve their quality of life. There was no evidence that staff have read and understood Policies and procedures. Guidelines for care practices within the home need to be developed further. All maintenance of equipment checks and all portable appliances have been completed and evidence was available. Indemnity Liability insurance is in place and the certificate was seen. All the weekly, monthly and yearly safety checks on appliances and systems in the home are implemented and documented evidence is available. The AQAA states that all the Fire system testing and training is implemented and recorded and that there is a Fire Risk Assessment in place. Water temperatures are monitored at outlets around the home and recorded to evidence that safe outlet temperatures are maintained. The hot water system is tested yearly for Legionella. The Manager has produced a Homes Annual Quality report that is based on questionnaires sent to relatives and residents and also looked at internal recording systems. Whilst the surveys demonstrate a quality system approach the other areas do not represent auditing but are more an explanation of why these systems are used and what the manager looks at. Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 24 The Quality Assurance System need to be developed further to include documented monitoring of all systems in the home on a regular basis (monthly/three monthly not just yearly) through management audit processes, so that continual improvement can be demonstrated in the home and an overview can be given through the yearly Quality Assurance Report. Surveys must include views of external stakeholders using the service, such as Social Services, GPs and CLDT etc. Evimiz DS0000068544.V370008.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 2 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 1 X 2 X 3 X X 2 X Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES 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 YA1 Regulation 4(2) Requirement The statement of Purpose and the Service Users Guide must be in a format that can be understood by the people using the service. (Repeat requirement from 10th September 2007) The following amendments to care record must be implemented: • All entries, reviews and amendments must be dated and signed to allow an audit trail of care and changes. • Where there is a risk assessment about behaviour and action to be taken this must be placed with the daily behaviourrecording sheet so that staff know what to do. Where specific instructions are given for management of individuals by Health Care Professionals this must be documented by them in the care file so it acts as a reference for staff. Timescale for action 30/11/08 2. YA6 15(4) 30/11/08 3. YA18 13(1b) 30/11/08 Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 27 4. YA20 13(2) 5. YA20 13(1&2) 6. YA23 22 7. YA34 19 & Schedule 2 8. YA35 18(1c) 9. YA36 18(2) 10. Evimiz YA39 24 (1-3) The Manager is to ensure that the Medication system within the home is fully compliant with the regulations and Guidance: • Records of medication ‘into’ and ‘out’ of the home are maintained. • Records within the home are accurately maintained. • Allergies are completed. • Staff specimen signatures are available with charts. • Resident photos are available with charts. • Medication training for all staff is arranged. • The Manager must implement a regular medication audit. (Repeat requirement from 10th September 2007) The Manager to implement a policy and procedure relating to the Management of Medication when people are going on a short break from the home. The Complaint procedure must be developed and available in a format that is completely accessible to the Residents living at the home. The Manager must ensure that recruitment procedures are followed for all staff and employment files contain all the required information in line with Regulation 19. All staff require challenging behaviour training for the client group to be cared for in the home. (Repeat requirement from 10th September 2007) Supervision arrangements for all staff must be put into practice so that they receive supervision six times a year. The Registered Person must DS0000068544.V370008.R01.S.doc 30/10/08 30/10/08 30/11/08 30/11/08 30/11/08 30/11/08 30/11/08 Page 28 Version 5.2 11. YA43 37 produce an annual quality assurance report that: • Evidences the regular review of the quality systems in the home. • Evidences the views and opinions of Stakeholders. • States future developments in the home. The home must inform the CSCI 30/10/08 of any event/incident that affects the health or wellbeing of an individual within their care. 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 YA23 Good Practice Recommendations The Manager must address with the Social Worker the issues relating to people not having access to their Personal allowance. Evimiz DS0000068544.V370008.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Evimiz DS0000068544.V370008.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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