Inspection on 10/11/05 for Faycroft

This inspection was carried out on 10th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Faycroft 09/05/07

Faycroft 27/06/06

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Faycroft New Street St Georges Telford Shropshire TF2 9AP Lead Inspector Rebecca Harrison Announced Inspection 10th November 2005 09:30 Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 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 Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 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. Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Faycroft Address New Street St Georges Telford Shropshire TF2 9AP 01952 616515 01952 640995 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) Care Tech Community Services Limited Mrs Paula Johnson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th June 2005 Brief Description of the Service: Faycroft is a care home registered with the Commission for Social Care Inspection to provide accommodation and personal care for a maximum of six adults with learning disability. The home stands in its own grounds and is conveniently located in a residential area of St. Georges, Telford, close to local amenities and just a short journey from Telford Town Centre. The new registered provider is CareTech Community Services Ltd who were registered with CSCI on 11.08.05. The responsible individual is Mr Stewart Wallace and the registered manager of the home is Ms Paula Johnson. Caretech’s philosophy is included in the Statement of Purpose for the home and states ‘CareTech and their staff workon the philosophy of enabling people to live as full a life as possible, supporting them in their daily activities and any identified long term plans. We recognise that all people with disabilties should be given due respect to their individuality enabling all to be fully involved in any decisions having an affect on their lifestyle commensurate to the level of their abilities and enabling people to maintain all their entitlement assocoiated with citizenship’. Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and commenced at 09.30 a.m. and lasted 4.5 hours. All of the current service users living at the home were present for the duration of the inspection. The inspection included talking with service users, staff on duty, managers and the area manager, observing activity, examination of records and case tracking and a part tour of the environment. The service users, staff and managers were most welcoming and helpful throughout the inspection. The purpose of this announced inspection was to consider the requirements and recommendations made under the previous registered provider at the unannounced inspection undertaken on the 20th June 2005 and to review the progress made by the home under the new registered provider, CareTech Community Services Ltd. There have been no complaints, no referrals to adult protection or additional inspections carried out since the last inspection of this service. What the service does well: What has improved since the last inspection? This is the first time this service has been inspected under the new registered provider, CareTech Community Services Limited. Staff commented that training opportunities are extremely good in that as soon as a training and development need is identified, training is quickly provided. All staff have received mandatory training in safe working practices and future training is planned which is linked to the individual needs of the Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 6 service users. Managers are now receiving training appropriate to their role for example recruitment and selection, supervision and appraisal. Staff commented that the quality of service has improved and the induction process more robust. The manager will have a greater control over the homes overall budget and be supported by the area manager in this process. 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. Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 7 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 Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 8 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): 1 Appropriate procedures are in place to successfully accommodate an admission to the home. EVIDENCE: No new service users have been admitted since the last inspection therefore it was not possible to assess key Standard 2 on this occasion. The home currently has two vacancies. A Statement of Purpose and Service user Guide were submitted to CSCI in preparation for the registration of the new providers. Both documents meet Schedule 1, Regulations 4 and 5 of The Care Homes Regulations 2001. A requirement was made at the previous inspection for service users to be provided with a copy of the contract, which has been signed by the service user and/or their representative and the manager. A copy of the contract was seen on the two service user files reviewed. It was reported that a copy of the contract has been sent to the parents of service users requesting a countersignature. Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 9 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 and 9 Care planning systems are in place to provide staff with the information they require to meet the individual assessed needs of the service users. Service users are enabled to make decisions and take responsible risks within a risk-assessed framework. EVIDENCE: Three requirements were made at the previous inspection in relation to behaviour management and risk assessments. The findings of this inspection evidenced that these requirements have been met. Under the new provider each service user has three files consisting of a support plan file, current file and a historical file. The support plan file is used daily and includes an individual support requirement form which identifies services uses assessed individual needs. After each shift staff are requested to complete a daily service record, which is a tick sheet. The form does provide space for additional comments, however very few of theses records seen included additional written comments about the care and support given to the service user or any structured activities that the individual had partaken. Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 10 The files were generally found well organized however some information was repetitive. It was reported that managers have been provided with training in the development of support plans through the organization. A key worker system is in operation. It was reported that none of the service users have received a formal review since the last inspection despite efforts being made by the home to arrange reviews with placing authorities. Managers were advised to review care plans internally in the interim. The home has previously utilized the services of an independent advocacy service however there has been no recent involvement. Managers reported that individual ‘Talk Time’ is to be introduced shortly. Future training is planned for promoting empowerment of service users. Observations made and discussions held evidence that service users are involved in decision-making. A number of risk assessments were seen on the two care files reviewed. CareTech have developed generic standard risk assessments which the home are required to add or remove bits to make them individualised, however the assessments refer to the client and therefore lack a person centred approach which was acknowledged by managers at the time of the inspection. Assessments seen on file evidence that service users are enabled to take responsible risks. Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 11 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): x EVIDENCE: The intended outcomes for all of the standards above were assessed and met at the previous inspection and were not reviewed on this occasion. Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 12 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): 20 Service users are safeguarded by the homes system of handling, storing and managing medication. EVIDENCE: The intended outcomes for key standards 18 and 19 were assessed and met at the previous inspection and were not reviewed on this occasion. Since the last inspection the home has changed pharmacists and Boots Chemists now supply the home with prescribed medicines. It was reported that the Monitored Dosage System (MDS) is now used and that staff have received training in the new system. The area manager is seeking ‘accredited’ medication training. Medication was found appropriately stored and well organised. Medication procedures appeared satisfactory at the time of the inspection. An Associate Specialist who is based within the local team regularly reviews prescribed medication. Risk assessments for administration of medicines is in place in addition to a protocol for PRN medicines. The homes policy on medication was not reviewed on this occasion. Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 13 In preparation for this inspection the CSCI received comments from a relative, general practitioner and two health and social care professionals and all stated that they were satisfied with the overall care provided. One health professional commented that staff have been very supportive in advocating the needs of one individual in particular and that he has always found the clients well cared for. Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 14 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): x EVIDENCE: The intended outcomes for key standards 22 and 23 were assessed and met at the previous inspection and were not reviewed on this occasion. It was reported that the home has not received any complaints since the last inspection. No formal complaints have been referred to the Commission for Social Care Inspection and there have been no referrals made under adult protection procedures. Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 15 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 and 30 Service users are provided with a safe, comfortable and homely place to live. EVIDENCE: People continue to be provided with a homely place to live and this was evident during a tour of the home. The area manager reported that she has recently obtained the budget for capital expenditure and a dishwasher is to be purchased, the carpets in two bedrooms are to be replaced and the bathrooms refurbished. The lounge suite is also in need of replacement, as it looks heavily worn in places and the foam is exposed in one of the arms. This should be included on the homes planned maintenance and renewal programme. Two service users were keen to show the inspector their bedrooms, and these appeared comfortably furnished and very personalised. The home was found very clean and tidy throughout and service users are encouraged to maintain a clean environment and assist with general household tasks. An offensive odour was detected on the first floor landing. The home has a policy for infection control and the area manager stated that this is covered in the LDAF induction training. COSHH Data sheets and risk Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 16 assessments have recently been updated and these were found well organised and the products appropriately stored. Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 17 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): 32,33,35 and 36 The staff have a good understanding of the service users’ support needs and are provided with the necessary training to meet the needs of the people accommodated. Higher staffing ratios would provide greater opportunities for community presence and participation. EVIDENCE: Seven requirements were made at the previous inspection in relation to staffing levels, training, supervision and appraisal. Staffing rotas seen evidence that there are a minimum of two care staff on duty to support the needs of the four people accommodated until 10pm when staffing levels reduce to one waking night staff with on-call support arrangements. The area manager was confident that staffing levels meet the assessed needs of the service users however it was reported that additional funding is to be requested for two individuals who require higher staffing levels for community presence and participation. It was reported that staffing levels would be further reviewed for any prospective service user moving into the service. Two staff hold NVQ awards. The home employs five care staff in addition to the manager. There are currently three vacancies, which are being covered by permanent staff, and Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 18 core agency staff that are familiar with the needs of the people accommodated. Staff spoken with commented that on occasions they are working double shifts from 8am to 10pm to cover vacancies, sickness and training etc. and such was evidenced on the staffing rotas seen. The only employee recruited since the last inspection has since left. The manager reported that one person has successfully been recruited through a recent interview and pre-employment checks are currently being undertaken. Therefore personnel files were not reviewed on this occasion. It was reported that managers have received training in recruitment and selection. CareTech provides a designated training officer based at the Head Office in London. The home receives regular training programmes from CareTech in relation to forthcoming training events. The programme seen at the inspection was comprehensive and included mandatory and service specific training opportunities. All staff have recently undertaken mandatory training through the new provider. Managers and staff spoken with were very complimentary regarding the training opportunities available. It was reported that the home are working closely with health professionals based within the local team in Wellington in relation to providing training in communication. The area manager stated that staff are to receive training in mental health in the near future as recommended at the previous inspection. The former acting manager reported that under the new provider she has received training in staff supervision and appraisal. It was reported that staff have received formal supervision however staff sickness has prevented it being undertaken at the required frequency. Supervision contracts are in place in addition to a formal supervision planner. It is CareTechs expectation that staff receive formal supervision monthly, which is monitored by the area manager. The registered manager committed to ensure that staff receive supervision on a regular basis. The organisation has a staff appraisal policy in place and managers have received training in appraisal. The appraisal documentation was shared with the inspector and appears comprehensive. It was reported that appraisals are usually conducted in the month of September. Due to the recent takeover of provider, managers have not yet had opportunity to undertake appraisals. Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 19 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): 37,41 and 42. The home is managed by a competent manager who appears committed to improving the service for the people in residence. The safe working systems in place promotes the health, safety and welfare of service users and staff. EVIDENCE: The Registered Manager, Ms Paula Johnson returned to work on 07.11.05 following maternity leave. Ms Johnson is contracted to work 40 hours per week with 16 hours designated for management duties and the rest of her hours are for providing direct care. Ms Johnson reported that she attended a number of CareTech training courses whilst on leave in order to familiarise her self with the new registered provider. Ms Johnson is awaiting her certificate for her NVQ level 4 Award and is shortly to commence the Registered Managers Award. Whilst Ms Johnson was on maternity leave the home was managed by Ms Abigail Crompton. Ms Crompton was present at this inspection and reported Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 20 that she has recently successfully gained a management position at another home managed by the organisation. The findings of this inspection evidence that she demonstrated a commitment to managing the home in the absence of the registered manager and has undertaken numerous training courses appropriate to the role. It was reported that under the new provider managers will have more control in relation to the homes budgets and will be closely supported by the area manager. A requirement was made at the previous inspection in relation to the development of a quality assurance system. It was reported that the new provider has a system in place and that training in quality assurance is planned to take place shortly. This will therefore be reviewed at the next inspection of this service. Records reviewed during this inspection were found well organised and appropriately stored, however some information particularly in the care planning documentation was rather repetitive and a member of staff spoken with said it can be time consuming to document the same information in a number of places for example health appointments. It is acknowledged by the inspector that managers and staff have worked considerably hard transferring information over to the new organisations record keeping systems. Sufficient information was available to evidence that the manager ensures, so far as is reasonably practical, the health, safety and welfare of service users and staff. Inspection of health and safety records indicate that regular checks and tests are being undertaken. Managers agreed to follow up the recommendation made on the Corgi Gas Landlord Certificate in addition to ensuring accidents are recorded as per data protection requirements. All staff have received mandatory training in safe working practices and generic risk assessments are in place. COSHH data sheets and risk assessments have recently been reviewed. A comprehensive health and safety manual is in place in addition to an appropriate policy. The Environment Health Department or Fire Safety Department have not visited the home since the last inspection. Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x x x x Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 2 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x 3 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Faycroft Score x x 3 x Standard No 37 38 39 40 41 42 43 Score 3 x x x 3 3 x DS0000065004.V263710.R01.S.doc Version 5.0 Page 22 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA30 Regulation 16(2)(k) Requirement The offensive odour on the first floor landing must be eliminated. Timescale for action 31/12/05 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 2 3 4 Refer to Standard YA6 YA32 YA41 YA42 Good Practice Recommendations It is recommended that daily service records contain written comments about the level of care and support given to the service user. 50 of the care staff should achieve a NVQ level 2 or above by 31.12.05 It is recommended that a more person centred approach be adopted for all records relating to individual service users. It is recommended that an index be developed for COSHH products that cross references to the appropriate data sheet for easier reference. Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Faycroft DS0000065004.V263710.R01.S.doc Version 5.0 Page 24 - 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. 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