Inspection on 18/04/07 for Follybridge House

This inspection was carried out on 18th April 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Follybridge House 18/04/08

Follybridge House 24/11/06

Follybridge House 07/02/06

Follybridge House 06/10/05

Follybridge House 28/02/05

Follybridge House 29/06/04

Follybridge House 24/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Follybridge House Bulbourne Road Tring Herts HP23 5UG Lead Inspector Steve Webb Unannounced Inspection 18th April 2007 10:15a Follybridge House DS0000022972.V331179.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 Follybridge House DS0000022972.V331179.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. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Follybridge House Address Bulbourne Road Tring Herts HP23 5UG 01442 828285 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) alan.wilson@turning-point.co.uk www.turning-point.co.uk Turning Point Limited Mr Alan Bruce Wilson Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 6 residents with a learning disability and mental illness Date of last inspection 24th November 2006 Brief Description of the Service: Follybridge House is situated in a quiet rural area, backing on to a nature reserve accessible to Service Users. The home has large, attractive and well-maintained grounds, which contain a sensory garden, a trampoline, and swings. The home is part of the charitable organisation Turning Point, which provides residential accommodation for people with learning disabilities and mental health problems. Follybridge House accommodates up to six male Service Users with behavioural problems and learning and communication difficulties. The current fees for this service according to the manager in the Pre-inspection questionnaire are £127.85 per week, though this relates only to the residential contribution by the resident, and is only part of the overall fees, with the remainder being paid by the referring authority. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit from 10.15am until 7.45pm on 18th of April 2007. This report also includes reference to documents completed and supplied by the home, and those examined during the course of the site visit. The report draws from conversation with the manager and with some staff members. Written feedback was obtained from the family of four of the residents via their completion of the residents’ questionnaires, on behalf of residents, and from two external healthcare professionals via the same route. Residents had no verbal communication with the inspector, so some time was spent observing the interactions between staff and residents as they went about their daily activities. The inspector examined the premises, and ate lunch with a resident. What the service does well: An appropriate system is in place for the preadmission assessment of prospective residents, and evidence from care plans indicates that there is also ongoing review and assessment of the needs of individuals. The detailed PCP care plans reflect the identified needs and known preferences of individuals, and set appropriate goals for improving skills and fulfilment. The behaviour management, and other care plans, are ratified by other parties, and regularly reviewed. The residents are supported as much as possible, to make choices in their dayto-day lives, though they have limited involvement in daily routines. Contact between residents and their families is supported wherever possible. A healthy diet is provided, and the specific dietary needs of one resident are well provided for, whilst trying to ensure his meals appear similar to those of other residents. Staff provide good support to residents, to meet their day-to-day needs, and where known, their preferences are acted upon; though there remains some scope for further development of the unit’s ability to meet residents’ needs in some areas. Residents’ healthcare needs are met effectively and their medication is managed effectively on their behalf. Residents are protected from abuse for the most part. (See below re management of residents’ finances). Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 6 The environment within the home is domestic and attractive despite the limitations on ornaments, plants etc. within communal areas, owing to destructive behaviour. The large enclosed garden is of real benefit. The residents are supported by competent staff, who receive a good induction and core training, and demonstrate a good understanding of their needs. Appropriate recruitment and vetting procedures are in place to provide protection to residents. The health, safety and welfare of residents is effectively promoted. The home is run by an appropriately qualified, and competent manager, who has instigated positive improvements in the service provided. What has improved since the last inspection? What they could do better: None of the residents is able to manage their own finances and the unit manages these on their behalf. Some items charged to residents, should have been met from the fees already charged. The manager needs to investigate this and ensure that any reimbursements due are made. Some improvement in residents’ opportunities to engage in activities, and for accessing community events, was noted, but there remains room for further development in these areas. Staffing levels are currently a limiting factor on further developing the level of residents’ community access, as well as reductions in the available day services support from external providers. The potential benefits of other communication systems should be explored for some residents maximise their communication repertoire. Though the views of residents are listened to and a complaints procedure is in place in text form, the manager should make available a more accessible Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 7 complaints format, once this has been consulted upon, to facilitate explanation of the process to residents. Some consideration should be given to the benefits of setting the trampoline into the ground at ground level. Although a good core training package is provided, further improvement is needed with regard to the level of NVQ attainment in the staff team. The current staffing levels are inadequate to meet the assessed needs of residents, particularly with regard to improving community access, in the light of existing risk assessments. The views of residents and others, regarding how they feel the unit is run, are not sought in a systematic way. Though a new system is being developed, it will need expansion to obtain views from the full range of relevant parties, and should culminate in the production of a summary report of findings. An annual development plan for the unit should also be produced arising from the annual review of the service and feedback from the QA and other systems. The provider must produce an organisational policy on physical intervention, to protect residents and staff. This is an outstanding requirement from the previous inspection. The provider must also make sure that the reports of the required monthly monitoring visits are provided to the unit. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Follybridge House DS0000022972.V331179.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 Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an appropriate system in place for the preadmission assessment of prospective residents, and evidence from care plans indicates ongoing review and assessment of needs. EVIDENCE: No new service users have been admitted since 2000, so it was not possible to judge the current assessment system in operation, though appropriate systems were in place to achieve this. Within Person Centred Plans there was evidence of effective ongoing assessment of needs, skills etc. though in the case of at least one resident it was clear that the identified current needs could not be addressed effectively within the current funding, with respect to staffing levels. The manager was seeking to address this with the funding authority and had secured temporary funding for the provision of an additional worker for periods when the resident was not attending day services, which is provided by an agency worker. However, in the long term this resident’s needs would be unlikely to be met effectively, without additional staff support on a more permanent basis. The Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 10 manager is due to attend a strategy meeting to address the future planning for this resident’s needs. The needs of this resident and the others mean that they are each risk assessed as needing the support of two staff when out in the community, and current staffing levels are therefore a limiting factor on the level of residents’ access to the community. This issue is addressed more fully elsewhere, but suggests the need to review and reassess the necessary levels of staffing to meet the needs of residents. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Though residents would have limited understanding of their care plans, these reflect the identified needs and known preferences of individuals, and set appropriate goals for improving skills and fulfilment. Efforts are made to ensure that behaviour management, and other care plans, are appropriately ratified by other parties, and are regularly reviewed. Within the limits of their understanding, residents are supported to make choices in their day-to-day lives, though they take a relatively limited part in daily domestic routines. None of the residents is able to manage their own finances and the unit manages these on their behalf. There is some question regarding whether some items charged to residents, should in fact have been met from fees already charged, which will need to be investigated. (A requirement is made under Standard 23 on this matter). Residents are supported to take some risks subject to an appropriate risk assessment system. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 12 EVIDENCE: Very detailed person centred plans (PCP’S), were in place for the two residents whose care was tracked, incorporating comprehensive information on supporting the resident at key times of the day, and during personal care and other routines. The PCP plans included identified goals, which provides for more effective monitoring and review of development and progress over time. The plans also included evidence that the preferences, likes and dislikes of residents had been ascertained over an extended period, in terms of how they are supported in meeting their needs. The residents all have complex needs and very limited verbal communication, and each has records detailing their individual communication methods, though there may be room for further development, through the use of additional communication systems such as the Picture Exchange Communication System (PECS), in some cases. The support of the speech and language service has been sought, appropriately, in the past. There is a large amount of information available for any new staff member to absorb, but the manager has asked keyworkers to produce a distilled version in the form of an individual profile for each resident, for new staff to read to enable them to commence working with them. All of the resident has individualised needs and presents challenges to the service, which are managed within individual behaviour management plans where necessary, to maximise consistency of approach. These plans are agreed with the CLDT (Community Learning Disability Team). Individual residents display some habitual/learned behaviours, which need to be addressed through a consistent approach. In order to assess the success of the chosen approach, the unit uses ABC charts and other recording to provide evidence in these areas. Work is under way to combine the best of several recording systems into one format in order to streamline recording demands. Residents’ daily records are currently maintained within a standard typed format, though consideration should be given to the possible benefits of their individualisation to enable the ongoing logging of significant events relating to behaviour management and monitoring on an individual basis. Such records might provide further support for keyworkers, in monitoring the effectiveness of behaviour management strategies, where perhaps the individual events/actions being monitored are beneath the threshold necessitating the completion of an ABC chart or incident report. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 13 All staff have recently received SCIP training to enable them to work more effectively with the more challenging elements of behaviour, through the early identification and intervention to diffuse potentially challenging situations and channel individuals into more constructive activity. The training also provides input on specific physical interventions when other techniques have been unsuccessful, though an organisational policy on physical intervention has yet to be produced, despite this being raised previously. The existing policy on “Managing Behaviour That Challenges the Service” is dated 2003 and does not fully reflect the complexity of the situation. (A requirement on this issue is made later, under Standard 40). It is understood that the provider is liaising with BILD (the British Institute for Learning Disability), to produce this policy. In the interim, the manager has compiled a policy in relation to the resident who most frequently challenges the service, which has been passed to the CLDT for approval. A range of relevant individual risk assessments were also on file, which indicated that all of the residents required two staff to support them as individuals within the community. Current staffing levels appear insufficient to support the ongoing development of residents’ access to events and facilities within the community, and this issue is addressed under Standard 33 within the staffing section later in this report. Background files contained evidence of the periodic review of needs, and a lot of the documentations now includes countersignature sheets to improve staff consistency and accountability. The keyworker for one of the tracked residents demonstrated a good depth of knowledge of his complex health needs and had compiled detailed records for other staff to support his care, including the development of an appropriate individual menu and recipe cards to assist staff in making his meals resemble those of the other residents wherever possible. The service is not staffed or geared-up to provide day-care services, and these are sourced from external providers. The day service previously provided on a long-term basis to one resident, has ceased following the closure of the provision, and in its place only limited support from an outreach team has been offered, which is not meeting the needs of the resident. The unit has responded appropriately in trying to pursue an alternative service from the local authority. The unit’s records effectively document the need for this service, via an increased incidence of challenging behaviour by the resident, since the withdrawal of the service. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 14 Residents take relatively little part in the day-to-day household routines and are risk assessments preclude their unsupervised access to the kitchen, or significant involvement in cooking and some associated food preparation. Where residents are involved, it is in such things as clearing and wiping the tables, sweeping, etc. and these tasks tend to hold their attention for very short periods at a time. This was observed during the inspection. The staff are familiar with the communication repertoire of residents as well as their long-term likes and dislikes and will try to meet the preferences of individuals. Simple choices were seen being offered wherever possible to try to encourage decision-making, with varying success. Feedback from four relatives, obtained via their completion of resident questionnaires, was very positive about the care provided, and staff keeping the family informed appropriately about any issues. One relative commented that their son’s care was “the best care he has ever received”. None of the residents is able to manage their own monies and the unit manages this on their behalf, in accordance with written financial procedures. Each resident has an individual bank account and small amounts of each resident’s money are held individually within the unit, either for them to spend with support or to be spent on their behalf. In/out/balance records are kept in individual books, together with details of what the money was spent on. Receipts are retained. Access is limited to the keyworker and unit manager. However, examination of a sample of these records indicates some expenditure of residents’ funds on items that would normally be expected to be provided from the home’s funds or the fees previously paid for the placement. A requirement on this matter is made under Standard 23 later in this report. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There has been some improvement in residents’ opportunities to engage in activities, and in their opportunities for accessing community events, but there remains room for further development in these areas. There is evidence that staffing levels are a limiting factor, as well as reductions in the available day services support from external providers. (Requirement on staffing levels made later under Standard 33). The unit supports contact between residents and their families wherever possible. Service users are encouraged to be involved in some daily routines, subject to risk assessment, but mostly choose not to take an active part. Residents are offered a healthy diet, and good provision has been made to meet the specific dietary needs of one resident whilst trying to ensure his meals appear similar to those of the others. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 16 EVIDENCE: New activities and goals formats have been included within the PCP care plans to provide planned opportunities for a range of activities and community access for each resident, though it is acknowledged there remains room for further development here. Activity planner folders are also in the process of development for each resident. It was said that the service is under some pressure from care managers to increase the levels of community access for residents. Staff felt they had made good progress in improving this aspect of the service. However, given the behavioural issues presented by residents, and their general dislike of large crowds, any increase in community access had to be gradual and well planned. One resident had been out within the community five times in a month, having two meals out, a picnic, a shopping trip and going swimming, so there is evidence of progress in this area, though it was suggested this was sometimes made possible only by staff returning in their own time to support rota’d staff to enable these outings to take place. Apart from the swimming, these activities also included other residents, due to staffing issues. As already noted, based on the fact that all six residents need two-to-one staffing when out in the community, the current staffing levels appear also to be a potential limiting factor to further development of residents’ access to events and facilities within the community. (This issue is addressed under Standard 33 within the staffing section later in this report.) Residents do visit a local pub and local restaurants, though they have been banned from a local hairdresser owing to previous behavioural issues. When taking residents out for meals, the staff often pre-order by phone to reduce the waiting time as this helps to reduce the risk of residents’ behaviour becoming an issue once in the venue. As already noted one resident has an interim funding agreement for an additional one-to-one staff member to support him, both within the unit and when accessing the community. Within the unit activities are limited, staff did not appear to engage in much art and craft activity, and it was said this was largely due to the very limited attention span of residents. No mention was made of such provision as music or drama sessions, aromatherapy or hand massage being provided by qualified external practitioners. This is an area with potential for further improvement. Residents do make good use of the large enclosed rear garden, which is provided with a sensory garden, sand/water equipment, swings and a trampoline, though records suggest that the trampoline is underused. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 17 Consideration should be given to setting the trampoline into the ground at ground level as this may increase its use as well as reducing the risk of injury. A greenhouse had been provided from a resident’s own funds owing to his evident enjoyment of horticultural activity within his day services, but he shows no interest in this provision at the unit. At various points during the inspection it was evident that the residents appeared restless and spent a lot of time walking about the unit and garden. Four of the residents went out to day services during the inspection, and the other two went along for the ride, returning later with the team leader. One of the remaining residents had lost his day care service due to its closure, and all that had been provided in its place was one-hour periods of support by two workers from the outreach team, who have no vehicle, so can only take the resident out locally for walks, such as to the nature reserve adjacent to the unit. The manager continues to try to negotiate for a more appropriate level of day-service support. Staff make detailed records of activities and outings with respect to what was more or less engaging and successful, as well as what techniques were necessary or most effective in addressing any behavioural issues. This is good practice as it helps plan effectively for future activities as well as providing, (alongside effective incident reporting and analysis), evidence of the levels of staffing needed, as well as identifying areas for possible future staff training needs. Residents have varying levels of family contact, though family are always invited to reviews and unit events, and some residents are escorted to and from visits to support this contact. As already noted, residents take a limited role in the domestic routines of the unit, with clearing tables and sweeping being most common. Some aspects are actively limited following risk assessment, such as kitchen access, which is only allowed with staff support and is very limited. It is not clear whether additional staffing could enable some development in these areas in the long-term. The menus are based on providing a balance of low fat and healthy options and also around the specific dietary needs of two residents. One has a very specific individual diet to address his medical condition as already noted and the keyworker has developed, (with some previous support from a dietician), an appropriate individual menu and recipe cards to assist staff in making his meals resemble those of the other residents wherever possible. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 18 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported effectively to meet their day-to-day needs, and where possible, their preferences are recorded, and acted upon; though there remains some scope for further development of the unit’s ability to meet residents’ needs in some areas. Residents’ healthcare needs are met effectively. Though residents are unable to manage their own medication, this is managed effectively on their behalf and with due regard to their preferences and rights. EVIDENCE: The care plans and other documentation give clear direction as to the needs of residents and, where identified, their preferences about their care etc. The unit is developing new formats to record incidents and their antecedents, from existing ABC charts and other formats, to streamline and focus recording, though copies of records of incidents relating to residents should also be retained within their case records. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 19 These together with risk management plans enable proper planning of the care of individuals. The limited communication and understanding on the part of the residents, presents difficulties in establishing their wishes and preferences about their care, though the long-term staff are familiar with how individuals express themselves, and some preferences were on record. It is possible that with some individuals there is scope for further development in this area, by the use of picture exchange and other systems, and the advice of a speech and language therapist might be beneficial. As already noted, there is a need to review the staffing levels at various times of day to enable the full range of needs of the residents to be met effectively, given that all currently require a two-to-one staff ratio, to ensure that residents have appropriate opportunities to access the community individually, and do not always have to go in pairs or groups to balance staffing needs. The manager is meeting with the local CLDT to agree individual behaviour management plans where necessary, to ensure that staff adopt a consistent approach to negative behaviours, in order to manage them effectively. Since the last inspection all staff have received SCIP, behaviour management training which will be regularly updated. This helps identify various interventions to try to prevent negative behaviour escalating, and provides for specific physical interventions where necessary as a last resort. Copies of articles on understanding challenging behaviour were also available. However, despite being a requirement of the last inspection, an organisational policy on the use of physical intervention has yet to be produced, though a draft is understood to be under discussion with “BILD”. A requirement on this issue is made under Standard 40 later in this report. The specialist healthcare needs of one individual are well documented and the home successfully addressed these and the associated dietary issues relating to this individual and another, who has swallowing problems. Staff demonstrated a good understanding of the residents’ healthcare needs. Appropriate support has been sought from external healthcare professionals, and feedback obtained from two such individuals was positive about the level of staff awareness of residents’ health needs. The sampled healthcare records were appropriately detailed and indicated recent and regular appointments where appropriate. Weight charts were also in place and had recent entries. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 20 Healthcare records include a record of appointment dates and a separate format to record any significant details regarding the visit. None of the residents is able to manage their own medication, and the home has an appropriate system in place to do this on their behalf, and a copy of the medication policy was present with the MAR sheets. Examination of a sample of records indicated appropriate recording and the presence of an effective audit trail for medication. The medication records file included photos of each resident at the beginning of each section. Individual PRN protocols and guidance on any variations to administration techniques was present and observed to be followed. Some residents take their tablets with a spoon of jam, but this is appropriately prepared in front of them. All staff received medication training in February 2007 from the pharmacist. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 21 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The views of residents are listened to and a complaints procedure is in place. The manager has drafted a more accessible version of the procedure that is being discussed with residents’ families, before being implemented. Residents are protected from abuse for the most part though the expenditure of residents’ funds on some items requires investigation and clarification. EVIDENCE: The unit has a complaints procedure in place, in written form, though none of the residents would be likely to be able to understand it in this form. Written guidance was present, on how to make a complaint on a resident’s behalf in an advocacy role, which is good practice. Staff did not feel residents would benefit from alternative versions of the complaints procedure owing to their limited ability to understand the written word, though it was noted in conversation, that at least one resident was able to communicate meaningful choices via the use of yes/no cards; so they may also be able to express dissatisfaction in this way. The provider’s Peer Review report also identified the absence of alternative versions of the complaints procedure as an omission. The manager subsequently provided a copy of a new partially pictorial complaints format, Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 22 which he was in the process of consulting on with residents’ relatives. This format is likely to be a good basis for explaining the procedure to residents. The complaints log indicated no recent recorded complaints. There is a written policy/procedure in place on the protection of vulnerable adults, which is accompanied by a staff signature sheet, containing recent signatures. The procedure is linked with the Regulation 37 notification requirements and copies of the local Adult Protection Procedure are also available. The unit also has a “Serious and Untoward Incidents“ policy Examination of training records indicated that most staff had received training on the protection of vulnerable adults in 2006 and previously in 2005, though it was not clear whether one staff had yet had this training. The manager should confirm that all staff have received training on the protection of vulnerable adults. A previous POVA issue was responded to appropriately. All staff have now received SCIP training on managing challenging behaviour, to ensure that appropriate and consistent approaches are used when residents demonstrate inappropriate behaviour, though the organisational policy on physical intervention is still awaited. Detailed systems are in place regarding the management of residents’ funds on their behalf including appropriate individualised records of expenditure and storage of small amounts of their funds, and each has an individual bank savings account. Only the manager and keyworker have immediate access to the funds of individual residents. One resident’s relatives are also involved in managing his finances. However, examination of a sample of the records of expenditure on residents’ behalf, raises some questions regarding whether some items charged to residents, should in fact have been met from fees already charged. Examples include the purchase of a single bed, and blinds for residents’ bedrooms, (the service user license agreement details window dressings and single beds as being included in the items supplied by the provide); as well as food and other household provisions and petrol, when on holiday, and the cost of the holidays themselves. Residents also pay for the meals of staff who are supporting them when they eat out as well as for the admission charges for the supporting staff when visiting attractions and events in the community. The provider’s Financial Procedures manual refers to the payment by residents, of staff meals, (at agreed subsistence levels), and staff entrance fees to Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 23 attractions, but makes no mention of other items. Instead it cross-referenced to the Service Level Agreement document, which was not readily available within the unit, a copy of which has been requested from the provider. These items would normally be expected to be funded from the placement fees, indeed residents already pay a weekly contribution towards their care from benefits, and a weekly contribution of over £39 towards transport costs. The resident’s own personal allowance is not intended to fund such items, and residents’ license agreements do not make these additional charges explicit. The manager must undertake an investigation of the use of residents’ funds to establish where items have been charged inappropriately to residents, and ensure their reimbursement. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 24 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a homely and safe environment, which is comfortable and pleasantly decorated, though there appears to be some reliance on the good will of staff in maintaining the standard of décor. The unit was found to be clean and hygienic, and has appropriate laundry facilities to meet residents’ needs. EVIDENCE: The unit was pleasantly decorated and furnished in a domestic style, though there were limited ornaments etc. in communal areas owing to aspects of the challenging behaviour of one or two residents. It was suggested that staff often undertook internal redecoration to ensure the environment remained to an appropriate standard. The provider should ensure that sufficient budgets are available to maintain the environment as and when required, without care staff having to undertake this role. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 25 Within most of the bedrooms, a greater degree of personalisation had been achieved and they were individualised to reflect the interests of their occupant. The environment meets the current needs of residents. The recent provision of electromagnetic holdbacks to internal fire doors has improved mobility around the unit. The home has a large enclosed rear garden, with swings, a trampoline, garden benches and umbrellas and a sensory area, as well as textured paved paths and areas of lawn. Most paths have a handrail. Consideration should be given to the benefits of setting the trampoline in at ground level. Standards of hygiene were good and the home has appropriate laundry facilities to meet residents’ needs. The home’s water is supplied from an underground spring, and the supply is regularly tested. There is a well in the garden, which is covered for safety. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 26 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34 and 35: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent staff who receive a good core training, and demonstrate a good understanding of their needs, though ongoing improvement is needed with regard to NVQ attainment. Current staffing levels are considered inadequate to meet the assessed needs of residents, particularly with regard to improving community access, in the light of existing risk assessments. Recruitment and vetting procedures are in place to provide protection to residents, and new staff receive an induction and a good core training to enable them to meet residents’ needs. EVIDENCE: The staff were observed to respond calmly and effectively and to support each other in managing instances of challenging behaviour, and worked hard to address the needs of the residents present. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 27 There were additional demands on staff owing to the withdrawal of day services from one resident, which meant that staff had to be allocated to meeting the needs of this individual throughout the day. The staff spoken to demonstrated a good level of understanding of the individual needs of residents and of addressing aspects of challenging behaviour, and felt more confident in this, having received the SCIP training. NVQ attainment in the unit is beneath the Government requirement, with only three staff reported to have NVQ level 2, two of whom are due to start level 3, though a further three are said to be due to commence their level 2. At the time of inspection, one support worker post was vacant owing to a recent dismissal, and one staff member was due to retire in the near future. Two bank staff were working regularly to provide the agreed temporary additional 1:1 support for one resident, pending ongoing funding for this. It was reported that vacancies had been advertised and interviews arranged. The regular staffing levels for the unit are three staff on duty throughout the waking day, and one waking night plus one sleep-in staff each night. At present temporary funding has been agreed for additional 1:1 support for one resident when he is in the unit, pending a permanent agreement on this or the provision of a more appropriate placement. However, owing to sickness and vacancies it has been common for there to be only three staff on duty. Casual agency staff are not appropriate in this unit owing to the needs of residents, so cover has tended to come from within the team or bank. Staff have also come in to support residents access to outside activities in their own time. Given that all of the residents are risk assessed as needing two-to-one staff support when out in the community the current staffing levels appear to be insufficient to support the ongoing development of residents’ access to events and facilities within the community, at least some of which should be possible without the need for other residents to also go along in order to try to balance staffing needs. The manager/provider must review the staffing levels in order to ensure that ongoing development of residents’ access to the community is supported effectively with regard to existing risk assessments. During the inspection a resident became agitated and snatched at a staff member’s neck breaking a chain she was wearing. Given the needs of the Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 28 resident group, staff should be reminded that it is inappropriate to wear neck chains and most other jewellery when on duty. The manager was off duty on the day of inspection so it was not possible to examine any recruitment records held on site. However, he subsequently confirmed verbally, that a new improved recruitment confirmation record was now being provided to the unit, which included the CRB check number and confirmation of appropriate clearance. The manager also confirmed that he saw applicants’ applications form, references, photo ID and other documents, during the recruitment process though copies are retained at head office. Examination of training records indicated a good core-training package, which now included SCIP (challenging behaviour management) training, POVA, medication, food hygiene etc. and training was also planned on autism and communication, though the date was to be confirmed. All new staff also receive an organisational and unit induction. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 29 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, 40 and 42: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is qualified and competent to run the home, and residents benefit from his clear leadership and motivation. The views of residents and other interested parties are not currently sought in a systematic way, regarding how they feel the unit is run. Though a new system is being developed, it will need further expansion to obtain views from the full range of relevant parties, and should culminate in the production of a summary report of findings. There is also a need to produce an annual development plan for the unit arising from the annual review of the service and feedback from the QA and other systems. The manager indicated subsequently that plans were in place to address these issues. There is an outstanding need for the provider to produce an organisational policy on physical intervention, to protect residents and staff. The majority of other policies and procedures were not examined on this occasion. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 30 The health, safety and welfare of residents is effectively promoted. EVIDENCE: The manager was off duty on the day of inspection but is appropriately experienced and qualified to manage the unit. He has attained NVQ level 4 and almost completed the Registered Manager’s Award. In conversation on the phone subsequent to the inspection the manager demonstrated a good understanding of the relevant issues and priorities for the unit, and feedback from staff, during the inspection was also very positive regarding his leadership and direct work with the residents. Regulation 26 monitoring visits had taken place in November 2006, January and March 2007, and copies of the resulting reports were on file. There was no evidence available, that these required monthly visits had taken place in December 2006 or February 2007. The provider is reminded that it is a legal requirement to undertake these visits on a monthly basis to monitor the operation of the unit and provide an opportunity for residents and staff to indicate any concerns they may have about the home’s operation. Reports of the visits must be copied to the unit and retained. The manager subsequently reported that the required visits had taken place, and undertook to locate the reports. There is currently no formal quality assurance system in place in the unit, a fact which was also highlighted in the recent Peer Inspection report. The provider operates a peer inspection system where management from one unit inspect other services. This system does not include consultation with service users, relatives or other interested parties, and is, as a result, more of a management audit system, though it provides a thorough audit of systems in that context. It was reported that previous quality assurance questionnaires to relatives had not generated a lot of useful feedback to develop the service, so there were plans for staff to meet residents’ families face to face to try to obtain more detailed feedback. Whilst this approach can be useful it should be remembered that not everyone may feel comfortable raising issues face to face, especially if they relate to the staff present at the time, so other alternatives might also be appropriate. The views of other interested parties such as care managers and external healthcare professionals should also be sought to obtain a rounded picture. Whatever system is adopted, the feedback obtained should be summarised in a report that is made available to participants and other interested parties. The Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 31 manager subsequently reported that he planned to respond individually to respondents and produce an action plan. It is difficult to seek the views of residents other than through working with existing staff, or family, with whom they are familiar, owing to their complex communication and behavioural issues. None would be able to complete a questionnaire for themselves. The service tried hard to obtain a good range of such feedback for the inspection questionnaires, by providing for their completion by family, keyworker or external professionals. The feedback obtained via these questionnaires was very positive about the care provided and the teamwork and current management of the service. No annual development plan was in place for the unit, with the action plan arising from the Peer Inspection, being the only forward-looking planning document in evidence. This document refers only to the issues raised within the Peer Inspection, and does not include other goals arising from wider QA feedback, so it does not satisfactorily meet the requirements of a unit development plan. The manager subsequently reported that an overall development plan/action plan for the service would be produced. A range of polices and procedures manuals were available to staff in the office, though for this inspection only a small number were examined. The existing policy on “Managing Behaviour That Challenges the Service”, dated 2003, does not fully reflect the complexity of the situation. A requirement had been made at the last inspection, for an organisational policy on physical intervention by staff, be produced, but this had yet to be put in place. It was reported that the provider was consulting with BILD regarding the draft policy. This policy must be put in place as a priority, to protect staff and residents. As noted earlier the manager had appropriately consulted the CLDT for one resident who regularly challenges the service, to agree an interim guidance document. Examination of a sample of health and safety-related certification indicated that relevant servicing took place with due regularity. Given the groundwater source of the unit’s water supply, additional checks of water quality were also in place. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 32 An appropriate fire evacuation procedure was in place, which addressed the issue of a resident’s possible refusal to evacuate in the event of fire, and the unit had an up-to-date fire risk assessment dated 20/9/06. A fire drill had taken place in January 2007. The internal fire doors had recently been fitted with electromagnetic holdbacks to provide an appropriate means for them to remain open during the day. Staff had received fire safety training in May 2006 and this was scheduled again for October 2007. Recent accident and incident records were examined for two residents, which indicted the level of incidents of challenging behaviour that staff are managing on a day-to-day basis. The forms relating to the current month are held in a folder for ease of staff access, and subsequently analysed and appropriately collectively filed. It was evident that the level of incident reports had increased (confirming the impression reported by staff regarding this), since the withdrawal of day care services from one resident. The manager was pursuing a strategy meeting to discuss the issue. The collective incident and accident recording system, thus allows patterns of behaviour and changes to be identified, as part of identifying and meeting changes in the needs of residents. However, copies of accident and incident forms should also be filed individually within the case record of the relevant individual(s) as part of their care history. Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 33 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 2 X 3 X Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 34 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA22 Regulation 13(6) Requirement The manager must review the expenditure of residents’ funds to identify any inappropriate charges made, and arrange for their reimbursement. The manager/provider must review current staffing levels with reference to existing risk assessments, to establish appropriate staffing levels to meet the needs of residents. The provider must ensure that copies of Regulation 26 monitoring visit reports are provided to the unit, as part of their duty to protect the welfare of residents. The provider must produce an annual development plan to evidence how the service to residents will be developed. The provider is required to ensure that they have a “physical intervention” policy in place to protect service users, staff and the public from harm. This requirement remains overdue from last inspection. Previous deadline 01/02/07 Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 35 Timescale for action 20/06/07 2 YA33 18(1)(a) 20/06/07 3 YA39 26 20/05/07 4 YA39 24 20/06/07 5 YA40 Appendix 2 20/05/07 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 5 Refer to Standard YA12 YA13 YA18 YA23 YA39 Good Practice Recommendations The manager should continue to identify ways to improve the level of activities for residents, both those provided by staff and via external specialists. The manager should continue to develop the level of community access by residents to appropriate events. The manager should consider exploring the possible benefits of alternative communication systems for some residents, with a speech and language therapist. The manager should ensure that all staff have received recent training on the protection of vulnerable adults. The provider should ensure that the quality assurance system includes the seeking of views from all relevant parties, and culminates in the production of a summary report for participants. Copies of accident and incident forms should also be filed individually within the case record of the relevant individual(s) as part of their care history. 6 YA42 Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 36 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Follybridge House DS0000022972.V331179.R01.S.doc Version 5.2 Page 37 - 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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