CARE HOME ADULTS 18-65
Fell Close (4) 4 Fell Close Scarborough North Yorkshire YO12 6ST Lead Inspector
David Blackburn Unannounced Inspection 11th October 2005 09:30 Fell Close (4) DS0000007835.V256768.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 Fell Close (4) DS0000007835.V256768.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. Fell Close (4) DS0000007835.V256768.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Fell Close (4) Address 4 Fell Close Scarborough North Yorkshire YO12 6ST 01751 474740 01723 364310 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) The Wilf Ward Family Trust Mr Lionel Aubrey Bede Linley Care Home 4 Category(ies) of Learning disability (0) registration, with number of places Fell Close (4) DS0000007835.V256768.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Registered for 4 residents with Learning Disabilities some or all of whom may have Physical Disabilities 22nd June 2005 Date of last inspection Brief Description of the Service: Fell Close is a dormer style bungalow situated in a residential district of the town. A former private dwelling it provides accommodation for a maximum of four residents. There are gardens to the front and rear accessible to residents. All bedrooms are for single occupancy. No bedroom has an en-suite facility. Sufficient communal facilities are provided. There are a number of communal areas including sitting and dining rooms. The staff provide care to residents with severe learning difficulties some of whom may have associated physical disabilities. Appropriate aids have been provided and adaptations made. The staff seek to provide a holistic care regime offering personal care, help, advice and guidance with daily living skills and activities, a catering service, a laundry service and cleaning and domestic duties. All care and services are offered in conjunction with, rather than for, residents. Social activities are arranged inhouse and at external locations. All residents are registered with local medical practitioners who can arrange access to more specialised services should the need arise. The staff team and residents have direct access to the Community Learning Disability Team. Fell Close is owned by the local health authority. The care and services are provided by the Wilf Ward Family Trust, a registered charity. Fell Close (4) DS0000007835.V256768.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection upon which this report is based was the second to be undertaken in the inspection year April 2005 to March 2006. It was carried out over four hours including preparation time. The focus was on those key standards not assessed at the first inspection in June 2005 together with those parts of other standards that were subject to a requirement or recommendation. Care plans were examined together with some policies and procedures. Discussions were entered into with the two staff on duty and a telephone conversation was held with the registered manager. The three residents were spoken with though their ability to communicate was very limited. Their feedback was mainly one-word answers, gestures or facial expressions. What the service does well: What has improved since the last inspection?
An increase in staffing hours ensured residents could take full advantage of day care facilities. The staffing increase together with the imminent replacing of the mini bus with two multi-purpose vehicles gave residents the opportunity of outings on an individual basis. Residents’ dietary needs and food preferences were met through the adjustments being made to the menus. Fell Close (4) DS0000007835.V256768.R01.S.doc Version 5.0 Page 6 The registered manager had completed the Registered Manager’s (Adults) National Vocational Qualification level 4 award. Major improvements to the premises were to commence in the very near future to further enhance the overall health and safety of the residents. 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. Fell Close (4) DS0000007835.V256768.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 Fell Close (4) DS0000007835.V256768.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): 0. None of these standards was assessed. EVIDENCE: Fell Close (4) DS0000007835.V256768.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): 7. Residents’ needs, preferences and choices on aspects of daily living were well recorded and acted upon. Their finances were well managed. EVIDENCE: The case files and care plans of the three residents presently accommodated at the home were examined. Each detailed how the individual resident wished to spend their day, recorded on a weekly diary sheet. The resident’s preferences regarding a number of activities of daily living were also recorded. None of the residents was able to handle their own finances. The staff managed the money on their behalf. A clear record was maintained for each resident showing income, expenditure and running balance. Regular reconciliations of the record against the actual money were recorded. The money was checked and no discrepancies were found. Fell Close (4) DS0000007835.V256768.R01.S.doc Version 5.0 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 16 and 17. Residents were able to take full advantage of planned and spontaneous activities. Residents were assured daily routines met their individual preferences. Regular menu reviews ensured residents’ dietary needs and choices were met. EVIDENCE: Improvements in staffing levels ensured residents were able to attend day care placements and take advantage of other activities inside and outside the home. The proposal to replace the mini-bus with two multi-purpose vehicles meant residents could be offered outings on an individual, as well as group, basis. Good use was made of local community facilities including shops, library, cafes and pubs. Residents’ names were on the electoral role. Their care plans however recorded their inability to exercise their right to vote.
Fell Close (4) DS0000007835.V256768.R01.S.doc Version 5.0 Page 11 Residents’ preferred daily routines were shown on their care plan. Home routines and rules were designed for the benefit of residents. Discussion with and observation of staff showed every care was taken to ensure residents’ right to independence, privacy and dignity were promoted and maintained. Staff had devised menus around the known likes, dislikes, preferences and choices of the residents. Nutritional needs were recorded. Staff spoke of the need to ensure the food provided was liked and enjoyed by residents. They were aware of “healthy eating” requirements but menus did not rigidly adhere to such principles. Occasional “treats” were on the menu. The present menus were being revised and updated. Staff were able to record their comments and ideas as to the overall suitability, for each resident, of what was being proposed. Fell Close (4) DS0000007835.V256768.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): 18, 19 and 20. Residents had their personal and healthcare needs appropriately met. Mistakes in medication recording could jeopardise residents’ overall health care. EVIDENCE: Discussion with and observation of staff showed that residents’ needs were at the forefront of their minds. They provided care with good attention to the maintenance of dignity and privacy. Male and female staff were on duty giving residents the right to care from a person of the same gender. Residents chose their own clothing with assistance from staff who ensured items purchased were age, sex and personality appropriate. Health care needs were detailed on the care plan. The reason for referral and outcome were detailed together with any follow-up. Specific health needs were fully recorded with the relevant information available for staff reference and use, for example care of those with epilepsy. Proper arrangements were in place for the receipt, storage, administration and return of medication. Scrutiny of the medication administration record sheets showed a number of gaps in recording. The registered manager must carry out a regular check of these sheets and immediately address any errors found.
Fell Close (4) DS0000007835.V256768.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Residents could be assured their concerns and worries would be addressed. They were safe from harm through good attention to issues of adult protection. EVIDENCE: The complaints policy and procedure were seen. A copy of the complaints procedure was displayed in the home. Written and pictorial versions were available. The procedure must be updated to reflect the change in the regulatory authority. A clear and precise policy and procedure were seen on adult protection. Staff on duty had received training on this issue through induction, external training and units undertaken as part of the work towards a National Vocational Qualification. They were well aware of the issues involved and related the Department of Health’s publication “No Secrets” to the present procedures. They were confident in their approach to any suggestion of alleged or suspected abuse. The registered manager should obtain a copy of the revised multi-agency protocol on adult protection. Fell Close (4) DS0000007835.V256768.R01.S.doc Version 5.0 Page 14 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): 0. None of these standards was assessed. EVIDENCE: Fell Close (4) DS0000007835.V256768.R01.S.doc Version 5.0 Page 15 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. Residents were cared for by staff who undertook good induction and foundation training. EVIDENCE: It was said that all staff undertook induction and foundation training. Recent appointments had been given an induction in the home and were presently undertaking external training to LDAF recommendations (Learning Disability Award Framework). Other courses were provided by the Trust or by external trainers. A number of staff had achieved a National Vocational Qualification in care to level 2 and 3. The recent influx of new staff had meant that there was a demand on the organisation to provide further opportunities for people to commence work towards this award. Fell Close (4) DS0000007835.V256768.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42. The registered manager must ensure attention to detail so that residents can continue to live in a well-managed, safe and secure environment. EVIDENCE: The registered manager had achieved the Registered Manager’s (Adults) NVQ4 award. During the telephone conversation with the registered manager, it was said that a draft questionnaire had been devised to seek views on the overall performance of the home. This must be finalised and distributed to all interested parties. The staff records had been previously examined at the registered provider’s headquarters and found to contain the required information. The fire logbook showed the last recorded fire drill as taking place in 2004. A fire drill must be carried out as a matter of urgency and then at the intervals recommended by the fire service. Drills must be recorded in the logbook.
Fell Close (4) DS0000007835.V256768.R01.S.doc Version 5.0 Page 17 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 X X X X X Standard No 22 23 Score 1 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X X X Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Fell Close (4) Score 3 3 1 X Standard No 37 38 39 40 41 42 43 Score 3 X 1 X 3 1 X DS0000007835.V256768.R01.S.doc Version 5.0 Page 18 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 YA20 Regulation 13(2) Requirement Timescale for action 17/10/05 2 YA22 22 3 YA39 24 4 YA42 23(4)(e) The registered manager must ensure medication administration record sheets are completed correctly at the time medicines are given out. The complaints procedure must 31/10/05 show the correct name and address of the present regulatory authority. (Previous requirement outstanding from 31/07/05). The questionnaire designed in 31/10/05 the home to seek views on the overall performance of the home must be distributed to all interested parties. A fire drill must be carried out 17/10/05 without delay and then at intervals in accordance with the recommendations of the fire service. (Previous requirement outstanding from 31/07/05). Fell Close (4) DS0000007835.V256768.R01.S.doc Version 5.0 Page 19 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 Refer to Standard YA23 YA32 Good Practice Recommendations The registered manager should obtain a copy of the revised multi-agency protocol on the protection of vulnerable adults and discuss this with his staff. The registered providers are reminded of the need for 50 of the care staff to have achieved a National Vocational Qualification in care to at least level 2 by 31st December 2005. Fell Close (4) DS0000007835.V256768.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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