Inspection on 23/06/06 for Fenn Court

This inspection was carried out on 23rd June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 25 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Fenn Court 16/02/07

Fenn Court 24/03/06

Fenn Court 31/10/05

Fenn Court 15/11/04

Fenn Court 10/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Fenn Court Broads Cottages Toothill Road Grimsby North East Lincs DN34 4ER Lead Inspector Mrs Jane Lyons Unannounced Inspection 23rd June 2006 08:00 DS0000002914.V302976.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 DS0000002914.V302976.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. DS0000002914.V302976.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fenn Court Address Broads Cottages Toothill Road Grimsby North East Lincs DN34 4ER 01472 358369 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) H4037@mencap.org.uk Royal Mencap Society Position Vacant Care Home 12 Category(ies) of Learning disability (12) registration, with number of places DS0000002914.V302976.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24/03/06 Brief Description of the Service: Fenn Court is a care home providing personal care and accommodation for adults aged 18-65 years who have a learning disability. It is part of the Mencap organisation. The home is situated in a quiet residential area in the outskirts of Grimsby and is close to local shops and amenities. The accommodation is of a domestic nature and is provided in three houses. Each house has four single bedrooms with hand basin; bathrooms to the ground and first floor; separate toilet; lounge and dining-kitchen. In front of the houses is a communal courtyard with car parking space. Each house has it’s own private rear garden. Weekly fees are: £647.40. Information on the service is made available to prospective and current service users via the statement of purpose, service user guide and inspection report DS0000002914.V302976.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over 1 day in June 2006. Prior to the site visit 10 relative surveys were posted out of which 7 were returned and 20 staff surveys of which 9 were returned. During the visit the inspectors spoke to the area manager, five staff and eight residents to find out how the home was run and if the people who lived there were satisfied with the care and facilities provided. The inspector looked around the home and looked at some records. Information received by us over the last twelve months was considered in forming a judgement. Prior to the visit the inspector referred to notifications sent to the Commission for Social Care Inspection, the event history for the home over the past year and the completed pre- inspection questionnaire. The site visit was led by Regulation Inspector Mrs.J Lyons What the service does well: What has improved since the last inspection? The environment had improved due to redecoration, refurbishment and recarpeting of some parts of the home, further improvements are planned. Thus creating a more homely and safer environment for service users. A training programme has been developed to identify the training courses needed for staff over the next six months and some statutory training has been provided which will better provide staff with the skills and knowledge they need to carry out their work. DS0000002914.V302976.R01.S.doc Version 5.2 Page 6 Medication procedures and practices have improved since the last inspection which better ensure the health and welfare of the service users. The care staffing levels have been reviewed and increased which has meant that staff do not work on their own in the evenings and weekends so often and that they can support service users to access more regular activities and outings. There was evidence that service users had been consulted and more involved in the running of the home. A new quality assurance system was in the process of being introduced and when fully implemented will better monitor the service provided at the home to ensure it meets the needs of the people using it and continuous improvements are made. What they could do better: The acting manager has a good understanding of the work required to improve the running of the home, but is struggling to meet many of the outstanding requirements due to the volume of work. The current staffing structure at the home has no assistant or senior post attached to it so the required work falls to the manager to complete, this should be reviewed to ensure the safety and welfare of the staff and residents is fully promoted and protected. Service user care plans must improve; individual service user plans were available however some records did not have enough information about all the needs of service users. This means the home was not able to show that all aspects of health, personal and social care needs of service user’s are identified and planned for. The supervisory arrangements for the home must improve to provide staff with the necessary guidance, leadership and support to ensure service users living in the home are safe and well cared for. Staff must be provided with training on dealing with difficult behaviours to provide them with the skills and knowledge to ensure the safety and welfare needs of the staff and service users are met. The home must report all serious incidents to the CSCI to ensure appropriate action has been taken to ensure service user’s safety and welfare. Staff must complete regular monitoring and recording of the fridge/ freezer temperatures and record the temperature of the hot food provided. This will ensure that staff are following the required food hygiene practices and promoting the safety of service users. Self-closing door devices which are linked to the fire alarm system must be used as opposed to door wedges which would compromise the safety of service users if there was a fire. DS0000002914.V302976.R01.S.doc Version 5.2 Page 7 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. DS0000002914.V302976.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 DS0000002914.V302976.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 5 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Progress has been made to further improve the homes admission process which will provide individuals with the assurance that their needs can be met prior to the coming into the home. EVIDENCE: There have been no new admissions to the home in the last twelve months, the home is fully occupied. Following the last inspection visit care plans and needs assessments have been obtained from the relevant placing authorities for all the service users in the home. Comprehensive documentation is in place to carry out assessments on potential new service users, which would guide staff on the actions to be taken to ensure that new residents needs are properly assessed and planned for, although this has not yet been tested. Terms and conditions documents were seen to be in place and signed for those service users which the inspector case tracked, however these documents were completed a number of years ago and need updating to ensure the details were current. DS0000002914.V302976.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Service users do not have care plans and risk assessments that reflect their full range of needs and choices, without this there is no assurance the service users health, personal and social care needs will be met. Some progress has been made towards involving service users in the running of the home. EVIDENCE: Three service user files were case tracked which involved examining the care plans and other associated records. Although there were care plans in place which generally covered the health, personal and social needs of the individual the quality and consistency of the information was varied. There were no inhouse needs assessments in place and although reviewed local authority assessments had been provided the plans had not been evaluated regularly nor reviewed/ updated and therefore some care records did not reflect the service users current care needs and care provision. DS0000002914.V302976.R01.S.doc Version 5.2 Page 11 Care Plans and risk assessments for one service user were not up to date e.g.plans for diet and mobility did not reflect current care support and there were no plans to support current interventions for recent problems with confusion and faking seizures. Problems with absconding from the home were identified on risk assessment however the document had not been reviewed to include contact via her mobile phone which staff confirmed was the main action to take; however a detailed risk assessment to support recent concerns regarding the management of the service users finances had been developed. It is important that any high risk areas identified on assessments have associated care plans in place to support the required care interventions. Another service users plan did not detail recent problems with abdominal pain and swollen legs/ feet even though the problems had necessitated a hospital admission. Discussion with staff and examination of the daily records evidenced that there were a number of service users in all three houses who regularly exhibited challenging behaviour, not all the service users had agreed and up to date behaviour management plans in place. Daily records in one service user’s file identified that there were regular incidents with another service user. The registered person must ensure agreed behaviour management plans are in place for all service users who exhibit challenging behaviour. This is needed to ensure the welfare and safety of service users and staff. Although incidents of challenging behaviour were being recorded there was no evidence that these incidents were being monitored and evaluated on a regular basis to ensure lessons can be learnt. Again this is needed to ensure the welfare and safety of the service user and staff and to ensure appropriate strategies are in place. The care plans and daily records are held in two separate files; following the case tracking exercise and discussions with staff it is evident care plans are not being used as ‘live’ documents. The inspector advised that documentation is combined into one ‘holistic system’, which would be more user- friendly for staff and service users. From discussion with the area manager there was evidence that the acting manager had done a lot of work in reviewing the service users care needs and drawing up revised task sheets however given the current quality of the care programme documentation it is imperative this information should form the basis of a full needs assessment and that priority be given to ensuring all service users care plans are completely reviewed. Although there are documentation templates in the procedures manual for needs assessments and care plans this format has not been used for any service user documentation in the home. DS0000002914.V302976.R01.S.doc Version 5.2 Page 12 Residents meetings are now held regularly in house 1; service users told the inspector that they enjoyed the meetings and how staff helped them to discuss the things they wanted to. A number of residents also from house 1 have now been involved in the recent staff selection process. Meetings in houses two and three have taken place but not regularly. One of the service users has experienced recent problems in managing her finances; following staff concerns advocacy services have been accessed and detailed risk management strategies put in place. There was evidence that the staff are trying to keep track of all the service users expenditure but this is proving difficult when the service user visits the bank independently. DS0000002914.V302976.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Good progress has been made to ensure individuals access more activities in the home and in the local community; this better ensures that they experience a full life. EVIDENCE: Residents are able to take part in a variety of valued and fulfilling activities, both in-house and within the community based on individual preference. During the visit service users were supported to attend out patient appointments, shopping trips, visits to local restaurants and two service users were leaving for a long-weekend trip to Skegness. One of the service users told the inspector that she was really looking forward to her trip to MacDonald’s for tea that evening. Staff confirmed that since the staffing levels had been reviewed they were able to take the service users out for more trips especially at weekends. Service users records demonstrated that service users had accessed more activities and trips in recent months. All the service users attend local authority day centres for a number of sessions; records did not evidence any joint planning and recording. Consideration should be given to this. This would promote a more consistent DS0000002914.V302976.R01.S.doc Version 5.2 Page 14 approach and show how activities accessed at the day centre fit in with activities provided in the home. None of the service users were currently employed at work placements although one individual had in the past and the area manager confirmed that support would be accessed in this area for the more able individuals. Service users residing in House 1 had more structured opportunities to develop social, communication and independent living skills. Staff reported service users were supported to manage shopping, cooking, cleaning and personal care. Feedback from the four service users confirmed this. Staff reported that they helped service users to maintain family contacts by sending cards at significant occasions such as birthdays and Christmas and supported service users on visits where this was needed. This means service users are enabled and supported to maintain family contacts. Feedback from the relative of one service detailed, “I am more than satisfied with the care my daughter receives, she is always happy, well dressed and clean. The staff are always welcoming and pleasant”. Many of the service users regularly visit relatives at home and one service user is currently supported to visit his mother in a local care home. One of the service users told the inspector that her boyfriend regularly visits the home and often stays for tea, that the staff help her plan and cook the meal which she really enjoys. Service users are provided with three meals a day, staff and service users confirmed that they all contribute to the menu planning. Nutritional assessments have been carried out which were generally up to date; one service users care plan had not been updated to include her diabetic and low fat diet. A number of the service users have weight gain issues and there was evidence that staff are working to provide healthy well balanced meals. Service users are referred to the dietician when needs have been identified. DS0000002914.V302976.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Improvements have been made towards ensuring the service users personal and health care needs have been met however the quality of the care documentation potentially places the service user at risk of not having their health and care needs identified and planned for. EVIDENCE: All the service users were registered with a GP and records of visits to health care professionals were maintained, there was evidence that service users had accessed annual heath checks. Documentation seen demonstrated that service users had recently accessed support from dieticians/ diabetic nurse specialist, physiotherapists, opticians, chiropodists, orthotic consultants, psychiatrist and the clinical psychologist. It is important that any changes to care provision from recommendations outlined by health care professional are included in the care plans. Discussion with staff suggested that they considered the needs were being addressed even though there was a lack of clear guidance in the plans. This approach is dependent on staff memory and good verbal communication systems. Residents are at risk of not having their health care needs met if these informal systems break down. This situation was also noted at the last inspection visit when a requirement was made for action to be taken to meet the shortfall. DS0000002914.V302976.R01.S.doc Version 5.2 Page 16 There was some evidence that new risk assessments had been developed to support changes in need however this was inconsistent; for example one service user had a detailed assessment in place to support increased risk of financial abuse yet a problem with faking seizures had not been addressed. The majority of risk assessments need reviewing alongside the general review of the care plans. The home has introduced health action plans for two of the service users case tracked, although the assessment part of the document was completed no plan had been drawn up; advice was given to contact the local authority for support to progress this matter. The management of medication systems in the home had improved. Medication records were checked for three service users as part of the case tracking process: transcribing records were correct with the medication records corresponding to the printed label on the medication. There were no signature gaps on the records. Storage in all three homes is very limited; staff should monitor the temperatures in these areas to ensure they do not exceed the manufacturers guidelines. The inspector was informed that a medication error had occurred the previous day; discussion with the area manager indicated this was a genuine error and appropriate follow up action had been taken by the home. Discussion with staff identified that one service user was having her medication administered in food. A medication care plan did not support this practice and there was no evidence to indicate that this had been agreed with the service user or their representative(s), thereby demonstrating a clear audit trail of decision-making. Training records evidenced that eight staff have completed accredited medication courses (two this year) which leaves a further eleven staff awaiting placement on the course. DS0000002914.V302976.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Adult protection procedures have recently been tested and found to be robust which affords protection for service users. The arrangements for dealing with challenging behaviours do not assure the safety and welfare of some service users and staff. EVIDENCE: A vulnerable adult investigation was carried out in the home earlier in the year; the findings were conclusive and the staff member was dismissed. In discussion with the inspector staff demonstrated an awareness of the procedures and their responsibilities for reporting allegations and suspicions of abuse. Eight staff have accessed adult protection courses in the past and four staff are scheduled to access the course in July. The home has a complaints procedure in place. The home had not received any complaints however feedback from the surveys sent to relatives highlighted that five persons were not aware of the complaints process and would not know how to make a complaint. This information was given to the area manager who confirmed that all relatives had been sent a copy of the statement of purpose for the home which included this information, however she would ensure that all relatives received a separate copy of the complaints procedure. A small number of service users display challenging behaviours. Records for two-service users were examined. One service user had an agreed behaviour management plan, the other did not. Records showed incidents of challenging behaviour were being recorded, mainly in the daily records. However there was DS0000002914.V302976.R01.S.doc Version 5.2 Page 18 no evidence to indicate incidents were being monitored and used in such a way to ensure lessons were learnt from the handling of an incident and that future interventions were modified as appropriate. This must now happen. Staff in house 1 had accessed challenging behaviour training three years ago to support the admission of a service user; there was no evidence to support staff had accessed refresher training. Staff in the other two houses had not accessed challenging behaviour training which is important for them to have the skills and knowledge to be able to deal with situations in a competent, consistent, safe and agreed way. It was noted that one of the service user’s rooms in house two remains locked during the day, the staff could not give any account of this nor was the decision documented in the service users care plan. DS0000002914.V302976.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Improvements to the environment better ensure the safety and comfort of the service users although further improvements are required. EVIDENCE: The inspector carried out a tour of all three houses. Since the last inspection works had been undertaken to improve the home in terms of decor and furnishings; new carpets, flooring and furniture had been provided and a number of areas redecorated; thereby creating a more comfortable and pleasant environment for service users. Further redecoration and refurbishment works are planned and the acting manager confirmed that funding was in place; more major works to the kitchen areas in all three houses remain outstanding. Mencap lease the properties through an agent, the acting manager is currently ascertaining who actually owns the properties and whose responsibility it is to fund the major repairs. All areas of the home were clean and tidy. The acting manager had completed an audit of all the service user’s bedrooms looking at the furniture provided to ensure compliance with NMS 26.2. A document has now been provided in service users plans to record where omission is due to service user preference or risk assessment. DS0000002914.V302976.R01.S.doc Version 5.2 Page 20 One of the service users rooms in house three has a door wedge in place to keep the door open, staff told the inspector it was to enable the staff to observe the individual and also to enable the service user to have independence in accessing his room as he could not use the door handle; a self closing device linked to the fire alarm system should be provided. The staff in house one also told the inspector that one of the service users does not like to have her bedroom door shut at night especially if there are storms; consideration should also be given to providing a self closing device for this service user’s room door to meet her needs. There has been a problem with the hot water supply in house one for a number of weeks, this has impacted on the service users as they are having at times to access bathing facilities in the other houses and there is no hot water to the wash basins in their rooms; the heating engineers are awaiting a part for the boiler and the acting manager confirmed she was chasing the issue up. The front areas of the houses were tidy and well maintained; they looked attractive with the flowers that had been planted. The rear gardens to all three houses would benefit from new garden furniture, new planting and consideration to provide something more stimulating for the service users to observe or experience e.g. sensory area, bird table, water feature etc. DS0000002914.V302976.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Improvements to care staffing levels have ensured better activity provision for the service users however insufficient management support is hampering the acting managers progress in improvements to the running of the home. Limited progress has been made in the training and supervision of staff and this could place residents at risk. EVIDENCE: Since the previous inspection the care staffing hours have been reviewed and increased. It was clear from discussions with staff and feedback from the surveys that they feel the staffing levels are much improved when the home is fully staffed; house three have experienced problems with staff sickness in recent weeks which has meant high usage of bank and agency staff and as a consequence a lack of continuity for the service users. The management hours have not been reviewed; although the acting manager has the support of the area manager she has no other management support at the home. It is clear that she has a sound grasp of the work needed to develop and fully implement all the management and documentation systems in the home and has made some inroads, however it is evident that she needs further support to ensure all the requirements are fully met given the large volume of work outstanding. DS0000002914.V302976.R01.S.doc Version 5.2 Page 22 The inspector examined a random sample of four staff files; two of whom had been recently employed. In general the majority of records were seen to be in place to comply with Schedule 2 of the Care Standards; one of the long term staff only had one reference in place which the acting manager confirmed she would chase up .Two recently recruited staff had CRB checks on file which had been provided following commencement of work; the acting manager confirmed that Pova First checks had been carried out prior to employment however records of these must be held on file. All other documentation was seen to be in place and satisfactory. There was evidence that new staff had completed or were still working through the induction programme which meets the National Training Organisations guidelines. The acting manager has completed a full audit of staff training needs and developed a detailed programme of all the training sessions that staff require over the next six months. There have been significant shortfalls in training accessed for staff at the home in the past especially with regard to statutory courses, which the new programme will address. Courses on moving/ handling, first aid, medication, fire safety, food hygiene, health / safety, infection control, epilepsy awareness/ rectal diazepam, vulnerable adults, person centred awareness and Makaton are currently being arranged. Managing challenging behaviour training must also be accessed for all staff in the home given the difficult behaviours exhibited by a number of the service users. From case tracking the four staff files, feedback and discussion with other staff there was evidence that the staff supervision programme has not been fully implemented. A number of staff have accessed regular sessions whilst other staff have not received any or only one session. This does not ensure that staff have the guidance and support to enable them to carry out their work correctly and place residents at risk of not having all of their needs met. No staff appraisals have been carried out; it is important that the training and development needs of the individual staff members are identified to ensure that the current training and development plan fully reflects the needs of the whole staff team. The inspector observed during the visit that staff acted in a respectful manner to service users and communicated appropriately. DS0000002914.V302976.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The acting manager has an understanding of the areas, which the home needs to improve. Progress forward has been limited and this does not ensure the health safety and welfare of residents. EVIDENCE: The area manager confirmed that the acting manager had begun her application process for registration with the CSCI. The acting manager has made progress towards meeting some outstanding requirements however progress forward to meet all the shortfalls has been limited due to the demands on her time and the volume of work required at the home. The acting manager was on sick leave, which has also impacted on the amount of improvement work she has been able to achieve. The registered person must review the current staffing structure to ensure that the acting manager has the resources to meet the outstanding requirements. DS0000002914.V302976.R01.S.doc Version 5.2 Page 24 Feedback from staff surveys and discussions with staff during the visit revealed that staff moral had improved considerably. Many staff said that they had raised issues with the manager and that she had dealt with these promptly and effectively; they considered the management very approachable. One staff member said that the rotas were much fairer now. Mencap provide corporate policies and procedures for the home, the majority having been issued in 2002; amendments are provided when changes in legislation or best practice have taken place. A small number of documents are provided in formats accessible to service users. A new procedure to follow in the event of fire had been developed in picture format and was seen to be in place in all three houses. There was evidence from the case records that the CSCI had not been informed of a number of incidents that had recently occurred in the home such as absconding, an accident and an admission to hospital. To comply with Regulation 37 the CSCI must be informed of all notifiable incidents; an audit must take place of all incidents which have occurred in the last four months and all incidents reported retrospectively. Although staff have accessed some recent mandatory training the majority remains outstanding. Records evidenced that service checks had been completed for all installations and equipment. The fire officer had visited the home in March 2006; the fire risk assessment was not available during the visit. Works to ensure the integrity of the fire doors has been started. Records to support regular fire safety checks were in place. Hot water was monitored regularly and records seen during the inspection were satisfactory; the problems with the hot water supply in house one has been covered previously in the report as has the use of the door wedge in house three. Records of hot food temperature probing and fridge/ freezer temperature recording has not taken place regularly in houses one and two. The records on house three were satisfactory. Individual service user risk assessments were completed, however many of these were not up to date or had been reviewed regularly. The acting manager discussed in detail the new formal quality assurance programme which she had started this month to implement. Monthly reviews of all aspects of the service will take place and action plans will be devised to support deficiencies identified, the environmental section had been completed for June. DS0000002914.V302976.R01.S.doc Version 5.2 Page 25 DS0000002914.V302976.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 2 34 3 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 2 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 x 2 X 2 3 X 1 x DS0000002914.V302976.R01.S.doc Version 5.2 Page 27 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Timescale for action The registered person must audit 31/08/06 all care plans for service users to check whether the information details all the service users current care needs and care provision. Where necessary care plans must be revised and updated. 31/08/06 The registered person must ensure that the service user or their representative are involved and agree the individual plan of care. This must be updated in light of changing needs ands must be reviewed at least monthly. (Timescales of 30.01.05, 28/02/06 and 28/05/06 not met) NEW TIMESCALE The registered person must 31/08/06 ensure where service users exhibit challenging behaviours, a behaviour management plan(s) must be developed. This must be subject to regular review and monitoring. The registered person must 31/08/06 devise and implement a system in the establishment whereby the recorded episodes of DS0000002914.V302976.R01.S.doc Version 5.2 Page 28 Requirement 2. YA6 15 3 YA9 YA23 13 & 15 4 YA23 YA9 13 5 A9 12 & 13 6 YA19 18 7. YA20 18 challenging behaviour are reviewed in a way that supports a review of each episode with a view to informing best practice in such circumstances. Timescale of 30/6/05 not met The registered person must 31/08/06 review all current risk assessments. Where necessary risk assessments must be revised and updated. The registered person must ensure they are agreed to by the service users or their representative. The registered person must 15/09/06 ensure staff responsible for completing service user care programme documentation and risk assessments have the necessary skills and knowledge. Where required, staff must be provided with care programme training and risk assessment training relevant to the areas of risk being assessed. The registered person must 31/10/06 ensure that all staff members involved with medication receive accredited training. (Timescale of 30.09.04 not met and new timescale of 30.01.05 not met. NEW TIMESCALE) The registered person must 31/08/06 ensure health action plans are developed for each individual service user. 31/08/06 The registered person must ensure care plans set out where medication must be administered in service users food/drinks. This practice must be agreed with service user and or their representatives and relevant professional staff to provide a clear audit trail for decisionmaking. The registered person must 31/08/06 DS0000002914.V302976.R01.S.doc Version 5.2 Page 29 8 YA19 13 9 YA20 13 10 YA23 13(6) 11. YA24 23 12. YA33 18 ensure that any restrictions to service users personal accommodation is clearly documented in their care plan. This practise must be agreed with the service user, their representative and relevant professional staff to provide a clear audit trail for decision making. The registered person must ensure that the work to repair/ refurbish the kitchen areas is carried out. Timescale 31/03/06 not met. NEW TIMESCALE The registered person must ensure that the manager has adequate staffing resources to effectively manage the service. Timescale of 28/02/06 and 28/05/06 not met. NEW TIMESCALE The registered person must ensure that all staff complete and are up-to-date with mandatory training. (Timescale of 30.01.05 and 31/03/06 not met NEW TIMESCALE) The registered person must ensure that all staff are given an annual appraisal with their line manager to review their performance against their job description and agree a career development plan. (Timescales of 31/10/04, 30/01/05 and 30/06/06 not met.) NEW TIMESCALE The registered person must ensure that the frequency of staff supervision provides staff with recorded supervision at least six times a year (pro rata DS0000002914.V302976.R01.S.doc 31/10/06 31/07/06 13. YA35 18 31/10/06 14. YA35 18 30/08/06 15. YA35 18 31/08/06 Version 5.2 Page 30 for part-time staff). (Timescales of 30/11/04, 30/01/05 and 31/03/06 not met). NEW TIMESCALE 16. YA37 8 The registered provider must provide a manager for the home who is registered as a fit person by CSCI. (Timescales of 30/10/04,30.01.05 and 31/03/06 not met ) NEW TIMESCALE 15/09/06 17 YA39 24 The registered person must 30/09/06 ensure that an effective quality assurance and quality monitoring systems are in place seeking the views of relatives, friends, advocates and stakeholders as well as service users. The registered person must provide an annual development plan for the home based on a systematic cycle of planningaction-review, reflecting aims and outcomes for service users (Timescale of 31/12/04,30.04.05 and 30/05/06 not met.) NEW TIMESCALE The registered person must 30/09/06 provide a suitably qualified nominated first aider at all times. (Timescale of 31/11/04, 30.01.05 and 31/03/06 not met) NEW TIMESCALE The registered person must 31/07/06 ensure that hot food probe readings are recorded. (Timescale of 30/8/04, 30.01.05 and 31/03/06 not met) NEW TIMESCALE) 18. YA42 13 19. YA42 16 DS0000002914.V302976.R01.S.doc Version 5.2 Page 31 20. YA42 23 The homes fire risk assessment 31/07/06 was last reviewed in March 2003 and must be reviewed at least yearly. (Timescale of 30.01.05, 28/02/06 and 14/05/06 not met) NEW TIMESCALE The registered person must ensure that the fridge and freezer temperature readings are monitored twice daily and recorded. The registered person must ensure that the use of door wedges in the home is prohibited and suitable self closing devices are provided if service users bedroom doors need to remain open. The registered person must ensure that staff receive training in managing challenging behaviour. The registered person must ensure that the home reports all notifiable incidents to the CSCI. 31/07/06 21 YA42 13 22 YA42 23 and 13 31/08/06 23 YA35 18 30/09/06 24 YA41 37 15/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The registered person should identify on care plans and risk assessments in service users individual plan the person who has written it; date implemented and date reviewed (if applicable). The registered person should consider reviewing the current documentation system to provide one current user-friendly system. The registered person should ensure systems are in place, DS0000002914.V302976.R01.S.doc Version 5.2 Page 32 2 3 YA6 YA13 YA11 4. YA22 which support joint activity planning and recording for service users attending day services to promote a more coordinated approach. The registered person should ensure that the relatives of service users are aware of the home’s complaints policy. The registered person should audit the home against the requirements of the Disability Discrimination Act 1995, part 3. The registered person should ensure that 50 of care staff achieves NVQ 2. The registered person should ensure that records of Pova First checks are provided in staff records to support employment prior to the return of the CRB check. 5. YA24 6. YA32 7. YA34 DS0000002914.V302976.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000002914.V302976.R01.S.doc Version 5.2 Page 34 - 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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