Inspection on 24/05/06 for Gombards

This inspection was carried out on 24th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gombards 14/09/07

Gombards 30/01/07

Gombards 27/02/06

Gombards 04/05/05

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 Gombards 6 London Road Welwyn Herts AL6 9EL Lead Inspector Louise Bushell Key Unannounced Inspection 24 May & 13th June 2006 10:00 th Gombards DS0000063291.V292880.R01.S.doc Version 5.1 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 Gombards DS0000063291.V292880.R01.S.doc Version 5.1 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. Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Gombards Address 6 London Road Welwyn Herts AL6 9EL 01438 712892 01438 712893 gombards.service@united.response.org.uk www.unitedresponse.org.uk United Response 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) Vacant Care Home 8 Category(ies) of Learning disability (8), Physical disability (8) registration, with number of places Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th February 2006 Brief Description of the Service: Gombards is a newly, purpose built home first registered in 2005. It was purpose designed with full wheelchair accessibility and was built as two self contained units each catering for four service users with learning and physical disabilities. The home which is jointly owned by Health, Social Services and by Aldwyck Housing Association is managed and run by United Response (a voluntary organisation). The home is situated in Old Welwyn, ideally for service users to access amenities and local services. Local shops and entertainments are only a short distance away from the home. The home consists of ample bathrooms and shower rooms to meet the needs of the service user group. Additional aids and adaptations are sited within the home and include the use of overhead tracking systems as required. The home is spacious and presents as a homely environment for service users. A new vehicle will be provided that can seat up to three wheel chair users. This will support in increasing activities external from the home and increasing life and independence skills. The range of fee’s are from £1,500 – 1,800 per week. Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first unannounced key inspection of the inspection year. The aim of the inspection was to focus on the number of requirements and recommendations made at the last inspection and to compete a detailed inspection on all of the key standards. This inspection took place over two separate visits to ensure that appropriate evidence was gained to make suitable judgements and also to provide accurate feedback to the management of the home. A total of 7.5 hours was spent at the home, engaging with service users, having a tour of the building, discussion with staff and inspection records. This service is still currently subject to a number of multi disciplinary meetings held under the joint working procedures for the Protection of Vulnerable Adults, following information and concerns brought forward by a whistle blower. A new interim manager has been brought into the home to drive through improvements and continue in the day-to-day management of the home. What the service does well: The service is able to provide specialist support to those who require aids and adaptations to support with their mobility. The home has ample bathing and showering facilities with overhead tracking in place. The managers of the service provide an on call support system for all staff out of hours ensuring that emergency advice is available 24 hours a day seven day a week. Following the last inspection two service users are now receiving a new day care provision through a company called N-ABLE. This is supporting them and providing days out which are specifically structured to meet the needs of the individual’s needs, preferences and choices. The environment is well presented and the home presents well with a homely feel. A number of staff working have known the service users for along time and thus are fully aware of their individual needs, likes and dislikes. Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? A number of improvements have been made following the last inspection and these include the development of pen pictures for service users, a new key worker structure, medication systems and management, a new care planning form, once fully completed this would be an effective tool. The service is able to provide specialist support to those who require aids and adaptations to assist in their mobility. The home has ample bathing and showering facilities with overhead tracking in place. Electric profiling beds have been purchased for most of the service users who require them. An additional epilepsy alarm mat is now in place to support the independence and maintenance of dignity and privacy of a service user with epilepsy at night. Apron holders are now in place in the bathrooms and the bathroom is now repaired following the last inspection. Following the last inspection staff supervision and appraisal have commenced. Records were available for inspection, although improvement has been made this must continue in line with statutory requirements and each staff member receiving a formal one to one supervision at least 6 times a year. The current interim manager of the home stated that annual appraisals for all staff are to commence imminently. During the inspection discussions occurred around holiday planning and staff and service users are being involved in the planning for the annual holiday, plans of which are yet to be confirmed. Following a number of changes to staffing and management, it must be noted that the current management team are working extremely hard to drive up standards and have all relevant systems in place to meet standards. The staff team are working hard to maintain consistency for all service users. The home is usually managed by a team of three comprising of a service manager and two deputy service managers, it must be recognised that currently there is an interim manager and one deputy service manager. Consequently this is having impact on the implementation of much needs systems and management of the home, as many areas require attention and improvements. United Response must consider the effects of this and the current situation of the home, in its long term efficiency and management. The current interim manager of the home stated that they will be liaising with the local fire authority for further information and advice regarding protocols for best practice in the service users best interest. Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 7 What they could do better: A number of requirements have been made following this inspection and for further details, the reader is encouraged to view the entire report. In summary areas for further development are as follows; Pen pictures to be fully completed, signed and reviewed. All risk assessments to be reviewed as directed. All care plans must be signed, dated and reviewed. Contracts for service users must be completed and held on file. A record of foods consumed must be evidenced. Individual weight records must be up to date. Temperature records must be maintained for the medicines cupboard. Date opening must be written on medication when opened for use. Medicines must not exceed their shelf life. Guidance must be in place for all staff. A homely remedies policy is required to be implemented A controlled drugs register is required. Balance’s carried forward must be written on MAR sheets so accurate audits and reconciliation can occur. The carpet in the downstairs lounge is to be cleaned/replaced. A redecoration plan to be completed for the entire premises for the year 2006 – 2007. Fire evacuations must contain details of the duration, time, people involved, and action required and be signed by those involved where appropriate. A detailed fire risk assessment to be in place. A signing in / out board to be implemented. Floor plans for the building to be available for all, in the event of a fire. All records regarding the employment of staff to be held on site, including, reference’s, evidence of CRB being sought, application form, induction, and training. Risk assessments must be in place for the safe use of gloves, the electric recliner chairs and for all profiling beds. Dishwashers to be replaced with suitable industrial machines to meet the needs of the home. The laundry room door to be closed at all times. Mops to be colour coded for safe use and cross infection purposes. Assessment Pro forma’s must be available and evidenced on new service users files. Monitoring systems must be consented to by service users and or significant others. Staff to complete LDAF training and comply with NVQ requirements. Each member of staff must have an individual training and development record. The garden area requires clearing. Please contact the provider for advice of actions taken in response to this Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 9 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 Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 10 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&5 Quality in this outcome is poor. This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place to support in the detailed assessment of new service users. Assessment tools for the admission of new service users are required to be in place, ensuring that a detailed assessment can occur using the recognised tool. Service user contracts are not in place. EVIDENCE: Currently the home is occupied with 7 service users and there is one current vacancy. All service users have been living at the home for a number of years. Policies and procedures are in place for the admission of new service users, however at the time of the inspection and following further contact with the home the assessment document for prospective new service users was not provided. An assessment tool is to be devised for the assessment of new service user, using a recognised and uniformed method. Assessments must be present on the service users file. The assessment tool can provide evidence of how the home meets the needs of the service users but also how the needs and aspirations of the service user are being considered and met by the home. Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 11 Evidence observed on the day of the inspection of the service provided to the current residing service users was comprehensive, however it must be noted that the current service users have been utilising the service for a number of years and a structured, uniformed pro forma must be available for any future new admissions. A sample contract was seen and appears to contain all of the required information. These must be implemented for individual service users and held on file. Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 12 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 & 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans are available, with service users assessed needs identified. Risk assessments are in place and cover a range of risks. There is a need for all documentation to be audited and reviewed to ensure continued review of care in meeting changing needs of the service users. EVIDENCE: All service users have an individual care plan and an allocated key worker to support them in the home. Detailed pen pictures are in place for all service users and provide good information about the needs, goals, likes and dislikes of the service user. There is a need for to ensure that information is continuously reviewed so that it remains up to date. The care planning system is a relatively new system introduced by the home. Whilst the system appears effective, there is a need to ensure that all care plans and risk assessments are reviewed, signed and dated to ensure they are active, up to date and that all relevant persons have agreed the care plan. Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 13 Due to a number of vacancies in the staff team at present it has been suggested that the manager consider providing training to long-term bank staff that can support and shadow in the interim so the needs of the service user are being reviewed and evidenced appropriately. This will ensure that the methods of the planning are person centred, involve the service user at each stage and ensure that care plans are active working documents, adhering to the company’s “promise”, aims and objectives. Individual daily notes and guidelines for the service users were observed. All service users are supported within the Care Management Framework and frequent reviews occur to ensure changing needs are continuously assessed and reviewed. The home holds service user meetings. However, due to high complex needs of the service user group, at times seeking views is mainly achieved through body language and facial expression. The home is linked to an external advocacy group and referrals are made as required. Ranges of risk assessments are completed within the home for necessary actions. These are detailed and contain all the required information. Activities and outings enjoyed by the service users ensure that service users are supported to take risks as part of an independent life style. Risk assessments must be completed for the use of electric chairs, gloves and profiling beds. Risk assessments must be reviewed as stated when the risk was identified. Records of service user weight must be maintained and monitored. Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 14 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, 15, 16 & 17 Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to the service. Activities are available and records maintained. Service users rights must be protected and respected. Menus are well balanced and thus provide a nutritious diet. EVIDENCE: All service users are now utilising a structured day care provision. Two of the service users are now accessing a new resource called N-ABLE. This service provides person centred services to meet the individual needs of the service users. This arrangement is until further plans have been negotiated and fully implemented. Day care programmes are provided to meet the individual needs of the service users. Outings into the local community are arranged with the service users. With the local shops and entertainment facilities being so close, staff and service users can walk easily to reach them. A new three-seater vehicle has been purchased Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 15 for the staff to use to increase the number of outings for service users. Records of outings are maintained in the daily notes of the service user. Planning for trips occurs on the shift planner, which enables each member of staff to arrange and support the service user in making choices to attend. On the day of the inspection a trip to the local pub was on the shift planner. However, this did not occur because of unforeseen circumstances but alternative in-house entertainment was provided. On the day of the inspection one service user was supporting staff in the preparation of the evening meal. Menu’s were inspected and seen to be nutritious, well balanced and healthy, providing choices. The deputy service manager stated that the menus are produced with the involvement of a dietician and is available for advice as is required. Meals were seen to be taken in an unhurried manner in a calm and relaxed atmosphere. A record of foods consumed must be maintained. A number of service users are supported through a monitoring system to ensure their individual safety whilst in their rooms, for example at night. There must be evidence of agreement in the service users care plan. Service users are supported to maintain relationships with friends and family as required/requested. Visitors are welcome to the home at all reasonable times. A number of service user have formal and informal befrienders. Information is available about advocacy services. Following a discussion with the staff and the management team it was established that the planning for annual holidays is taking place. Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 16 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 & 20 Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to the service. Service users receive personal support in the way that they prefer and require. Service users physical and emotional health needs are met. Medication systems are well managed with a few areas requiring further attention to ensure safety for all. EVIDENCE: Service users have the technical aids and equipment they need for maximum independence (which staff are trained to operate as needed), determined by professional assessment, reviewed and changed or replaced promptly as the service users’ needs change, and regularly serviced. Service users receive additional, specialist support and advice as needed from physiotherapists, occupational therapists, speech therapists and others for, for example example, positioning or modification of equipment. Times for getting up/going to bed, baths, meals and other activities are flexible Personal support is provided in private, and intimate care is provided by a person of the same gender where possible and if the service user wishes Service users’ preferences about how they are guided, moved supported and Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 17 transferred are complied with, and reasons for not doing so are explained and recorded. Staff ensure consistency and continuity of support for service users through: i. ii. Designated key workers. Individual working records setting out the preferred routine, likes or dislikes of service users who cannot easily communicate their needs and preferences; and partnerships with advocates, family, friends and relevant professionals outside the home, subject to the service user’s consent. Records are kept of all medicines received, administered and leaving the home or disposed of to ensure that there is no mishandling. A record is maintained of current medication for each service user. Medicines in the custody of the home are handled according to the requirements of the Medicines Acts 1968, guidelines from the Royal Pharmaceutical Society of Great Britain and the requirements of the Misuse of Drugs Act 1971. Medicines are administered by designated and appropriately trained staff. The administration of controlled drugs is witnessed by another designated appropriately trained member of staff. The registered manager seeks information and advice from a pharmacist regarding medicines policies within the home and medicines dispensed for individuals in the home. Staff monitor the condition of the service user taking medication and call in the GP if staff are concerned about any change in condition that may be a result of that medication, and prompt the review of medication on a regular basis. The home uses a monitored dosage medication system, which was in general well managed. Good MAR sheets were observed with appropriate coding being used as required. Temperature records must be maintained for the medicines cupboard. This is being relocated to the dining room, following the last inspection. A new controlled drugs cabinet has been purchased and a register is required. Date opening must be written on medication when opened for use. Medicines must not exceed their shelf life. Guidance must be in place for all staff. Balances carried forward must be written on MAR sheets so accurate audits and reconciliation can occur. Photographs are now in place on the MAR sheets, there is still a need for the home to detail known allergies on the MAR and if there are no know allergies this should be entered in the event of an emergency. Clinical waste bins have been purchased and appropriate contracts are now in place. A homely remedies policy is still required to be implemented. Service users are supported in managing their own health care issues and documents are maintained of individual visits with clear actions as required. Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 18 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 & 23 Quality in this outcome is poor. This judgement has been made using available evidence including a visit to the service. A complaints procedure is in place for service users to utilise as required. The Protection of Vulnerable Adult policy is in place and staff have received some basic training and awareness. Staff records were not fully available for inspection and lacked evidence such as CRB and references, EVIDENCE: No further complaints have been received following that last inspection. The Adult Protection Team are still managing the issues as identified in the last report. Progress has been made and now a number of staff have been suspended from duty still pending outcomes. The home and the current management team have been working along side Hertfordshire Adult Care services, social workers and other relevant professionals throughout the investigation. Staff have received some basic training in protection awareness and issues as defined in the multi agency policy. Thorough inspection occurred of staffing records and many did not contain the required information. Evidence of CRB disclosures were not available on a number of files nor were references. Head office hold this information and attempts were made to fax across some of the items required, however a number still remained outstanding. All staff personnel records are required by legislation to be held on site and to be available for inspection at all times. Gombards DS0000063291.V292880.R01.S.doc Version 5.1 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 & 30 Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to the service. Gombards is a recently purpose built facility providing a homely and very well appointed living environment for all service users. Overall the building is well maintained and provides a safe environment for all staff and service users, however a number of requirements have been made with reference to the general management of specific areas around health and safety. EVIDENCE: On the day of the inspection the home was found to be clean and hygienic. Each service user has their own bedroom, which have all been personalised to suit individual tastes. The home’s premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users’ individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. The premises are safe, comfortable, bright, cheerful, airy, clean and free from offensive odours, and provide sufficient and suitable light, heat and ventilation. The home offers access to Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 20 local amenities, local transport and relevant support services, to suit the personal and lifestyle needs of service users and the purpose of the home. The premises are in keeping with the local community and have a style and ambience that reflect the home’s purpose. The premises are accessible to all service users. Furnishings, fittings, adaptations and equipment are good quality, and are as domestic, unobtrusive and ordinary as is compatible with fulfilling their purpose. The home must complete an annual maintenance and renewal programme for 2006 – 2007. Laundry facilities are sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten and do not intrude on service users. Hand washing facilities are prominently sited in areas where infected material and/or clinical waste are being handled. Policies and procedures for control of infection include the safe handling and disposal of clinical waste; dealing with spillages; provision of protective clothing; hand washing. Washing machines have the specified programming ability to meet disinfection standards. The two dishwashers were out of order at the inspection. There is a need for the home to purchase replacements that meet the needs of the service and thus it is recommended that they are replaced with suitable industrial ones. The laundry room door to be kept closed. Mops to be colour coded for safe use and cross infection purposes. There is a need for the carpet on the ground floor lounge to be replaced/cleaned. The garden area requires cleaning up and sorting to ensure that the space is user friendly and pleasant. A detailed fire risk assessment must be implemented. Advice was provided to the management team regarding accessing a template document. Fire evacuations must contain details of the duration; time, people involved, and action required and are signed by those involved. A signing in / out board to be implemented. Floor plans for the building to be available for all, in the event of a fire. Gombards DS0000063291.V292880.R01.S.doc Version 5.1 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, 34, 35 & 36 Quality in this outcome is poor. This judgement has been made using available evidence including a visit to the service. Training records are required to be maintained for all staff giving a clear picture of training needs. NVQ and LDAF must be completed by the required number of staff. Staff must be suitably supported and supervised with an annual appraisal. EVIDENCE: A current staff training schedule was provided for the inspection. Staff working in learning disability services use Learning Disability Award Frameworkaccredited training to provide underpinning knowledge for progress towards achieving R/NVQ’s. It was identified that only one member of the current team has undertaken this course and therefore it is required that additional staff complete this as part of their individual training and development. The registered person ensures that there is a staff training and development programme which meets Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. The home has a training and development plan, dedicated training budget, and designated person with responsibility for the training and development programme. Each staff member has an individual training and development assessment. A training needs assessment is carried out for the Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 22 staff team as a whole, and an impact assessment of all staff development is undertaken to identify the benefits for service users and to inform future planning. Currently there are a number of posts not filled with permanent staff, however the home has recently employed three new members of staff and are awaiting clearance. Staff have regular, recorded supervision meetings at least six times a year with their senior/manager in addition to regular contact on day-to-day practice. Staff have an annual appraisal with their line manager to review performance against job description and agree career development plan. The interim manager of the home has made an accredited start on the supervisions and plans to commence with the annual appraisals as soon as possible. Gombards DS0000063291.V292880.R01.S.doc Version 5.1 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 & 42 Service users are well cared for however there is a need to review the management levels in order for standards to be driven forward. Work and systems need to be fully implemented for the benefits of the service users, including quality assurance and safety practices. Quality in this outcome is poor. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. The current interim manager is suitably experienced and qualified to run the home. Currently there is the service manager and one deputy service manager, in order for the home to be managed whilst raising standards there is a need for this to be reviewed. Usually there is an additional deputy service manager and thus it is Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 24 recommended that an additional interim manager be appointed to support the current team. Effective quality assurance and quality monitoring systems, based on seeking the views of service users must be in place to measure success in achieving the aims, objectives and statement of purpose of the home. There must be an annual development plan for the home, based on a systematic cycle of planning – action – review, reflecting aims and outcomes for service users. The registered manager and staff can demonstrate year on year development for each service user, linked to implementation of the individual plan. Feedback must be actively sought from service users about services provided. The views of family, friends and advocates and of stakeholders in the community (e.g. GP’s, teachers, chiropodist, audiologist, voluntary organisation staff) must be sought on how the home is achieving goals for service users. There are a number of areas that have already been identified throughout this report that require further attention in order for compliance with the standards to be achieved. This includes in brief, fire practices, fire risk assessment and recording, reviewing of all risk assessments, implementation of a number of risk assessments, replacement of mops with appropriate colour coding and medication issues. Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 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 3 23 2 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 2 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 2 X Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 (1) Requirement An assessment tool must be in place for the assessment of new service users prior to and during the admission period to the home. All entries made into the residents care plans must be signed and dated and reviewed. Pen pictures must be reviewed, signed and dated. (This requirement has been carried forward from the last inspection. Noncompliance may result in enforcement action being taken). Regular attention must be given to the maintenance of the garden. (This requirement has been carried forward from the last inspection. Noncompliance may result in enforcement action being taken). Risk assessments must be reviewed as stated on implementation. Risk assessments must be implemented for; • The use of gloves. DS0000063291.V292880.R01.S.doc Timescale for action 31/08/06 2. YA6 17 31/07/06 3. YA24 23(2)(o) 30/07/06 4. YA9 13 (4) 31/07/06 Gombards Version 5.1 Page 27 5. YA34 19 & 13 (6) Schedule 2 (5) 6. YA16 12 (4) (a) 7. 8. YA17 YA24 16 (2) & 17 23 9. YA20 13(2) • Electric recliner chairs. • Profiling beds. To ensure the protection of the residents full CRB checks and two references must be taken up for all new staff before appointments are confirmed. Staff records must be accessible and held on site. (This requirement has been carried forward from the last inspection. Noncompliance may result in enforcement action being taken). Consent must be sought and recorded with regards to the use of any night monitoring systems in the home. Records must be available for foods consumed by the service user. The home must have a planned maintenance and renewal programme for the fabric and decoration of the premises, with records kept. The ground floor lounge carpet requires replacing / cleaning. Two industrial dishwashers are required to meet infection control requirements and the needs of the home. Temperature records must be maintained for the medicines cupboard. Date opening must be written on medication when opened for use. Medicines must not exceed their shelf life. Guidance must be in place for all staff. A homely remedies policy is required to be implemented. A controlled drugs register is required. DS0000063291.V292880.R01.S.doc 30/06/06 31/08/06 31/07/06 31/08/06 31/07/06 Gombards Version 5.1 Page 28 10. YA32 11. YA37 12. YA39 13. YA42 Balance’s carried forward must be written on MAR sheets so accurate audits and reconciliation can occur. (A number of these requirements have been carried forward from the last inspection. Noncompliance may result in enforcement action being taken). 18(i)(c)(i)&(ii) Appropriately trained and competent staff must be employed within the home. All staff must be trained in providing a person centred service to the residents in Gombards that meets their needs. • LDAF and NVQ training must be provided. • Each staff member must have a training and development plan. Showing training received and planed, with review and retraining dates. 24(l)(a)&(b) It is a requirement that the management continues to introduce and review the new work practices in the home. Sufficient management support must be in place for the efficient running of the building. 24 (1) a & b Effective quality assurances (2) & (3) systems must be in place. A quality assurance policy must be implemented. 23 (4) & (5), Fire evacuations must contain 13 (4) & (5) details of the duration, time, people involved, and action required and be signed by those involved where appropriate. A detailed fire risk assessment to be in place. DS0000063291.V292880.R01.S.doc 31/07/06 31/08/06 15/09/06 31/07/06 Gombards Version 5.1 Page 29 14 15 YA5 YA19 5(i)(b)&(c) 12 A signing in / out board to be implemented. Floor plans for the building to be available for all, in the event of a fire. The laundry room must remain closed at all times. Colour coded mops and buckets must be in place for the cleaning of different areas. All service users must have up to date contracts. These must be held on file. Accurate monthly weight records must be maintained for all service users. 31/08/06 31/07/06 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. 2. Refer to Standard YA24 YA7 Good Practice Recommendations It is recommended that the Sensory Room is arranged so that residents can benefit from the use of this facility. It is recommended that notes of the key-workers consultations with the residents are made in their care plans to act as a formal record of the facts and to evidence regular consultations with them. 50 of staff should be trained to NVQ level 2. 50 of staff should be trained to NVQ level 2. 3. 4. YA35 YA32 Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Gombards DS0000063291.V292880.R01.S.doc Version 5.1 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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