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Inspection on 20/07/05 for Gorse Farm

Also see our care home review for Gorse Farm for more information

This inspection was carried out on 20th July 2005.

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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a team of enthusiastic staff who have a good knowledge of the needs of the people in their care. Observations revealed positive relationships between staff and service users. Members of staff actively encourage service users to take responsibility for as many things are they are able, within their individual capabilities. There is evidence of service users receiving regular health checks and monitoring, and records are maintained. Staff at the home seek input from other health and social care professionals to assist in meeting individual need. A choice of food is available depending on the personal preferences of service users. The home provides a range of comfortable, safe and accessible shared space, which meets the assessed needs of the service users. Facilities available in the home consist of an allotment, sensory garden, sensory lounge, an indoor and outdoor keep fit area, punch bag and running machine, each bungalow has two lounges. The daycentre also has facilities for cooking and sensory massage as well as a second sensory room, quiet lounge and large area for craftwork and music sessions. Some redecoration of the bungalows has taken place since the inspection in January 2005, as required.

What has improved since the last inspection?

Staff are working with the Speech and Language Therapist to develop `Communication Passports` for individuals. This is a document that will guide staff on the communication methods used by individuals. The team leader in bungalow two is currently leading the process to update the care planning system. He stated that a new care planning system is to be introduced and that some work has commenced to cross reference risk assessments to care plans. The home is working towards the introduction of health action plans. This is something that the Government paper, `Valuing People` recommended that each person with a learning disability had by 2005. This is to ensure individuals receive all the care they need to stay healthy. Two service users have 1:1 support due to their high level of need. Previously this support has been provided by agency staff but for one individual a team of three permanent staff have been recruited. Some redecoration of the bungalows has been undertaken.

What the care home could do better:

The Manager must ensure that agency staff used by the home have the right experience, skills and training for the role they are undertaking. The Manager must ensure that staff records contain CRB information to evidence that service users are appropriately safeguarded by the home`s recruitment practice. Records on the use of physical intervention require improvement to ensure they meet current good practice guidelines. The home must also ensure they inform the CSCI of any incident where physical intervention has been used. The home must improve some areas of Health and Safety and make sure the home is safe for the people who live and work there. The care plan system must be reviewed to ensure staff can easily access information. Each risk assessment should be directly cross-referenced to the element(s) of the care plan to which it relates, and vice versa, so that the reader is naturally directed from one to the other.

CARE HOME ADULTS 18-65 Gorse Farm Coleshill Road Marston Green Solihull B37 7HP Lead Inspector Kerry Coulter Unannounced 20 July 2005 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 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 Stationary 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. Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Gorse Farm Address Coleshill Road Marston Green Solihull West Midlands B37 7HP 0121 770 9085 0121 770 9647 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Autism West Midlands Mrs Gail Ann Jennings Care Home 14 Category(ies) of Younger Adults, Learning Disability [14] registration, with number of places Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 31 January 2005 Brief Description of the Service: Gorse Farm is part of the Autism West Midlands group, which provides a range of residential, day care, education and employment opportunities for people with a diagnosis of autistic spectrum disorder. Gorse Farm provides residential and day services to fourteen young adults with an autistic spectrum disorder. Gorse Farm is located in the village of Marston Green. The converted barn facilities and specifically developed buildings comprise of an administration building, two purpose built separate bungalows and a day centre. The two bungalows comprise of seven single bedrooms, lounge, dining room, and an additional lounge with sensory stimulation equipment, kitchen and a range of toilet and bathroom facilities, laundry and staff facilities. The day service building comprises of art and craft facilities, kitchen, fully equipped sensory room, music and drama area, computer room and quiet workrooms. The establishment is set in spacious and private grounds and are formed around a quadrangle with a lawned area. The home also has a sensory garden and allotment for the use of the Service Users. There is ample parking to the side of the home. Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was conducted by one inspector. The inspector spoke with several service users but they did not comment on their general satisfaction with the home. Time was also spent observing care practices, interactions and support from staff. A tour of parts of the building and garden was made. The day centre was not visited at this inspection. Service user care plans and risk assessments were inspected. Staff training and recruitment procedures were examined, and a number of Health and Safety records were inspected. The inspector had the opportunity to talk with the Deputy Manager and several members of staff. During this visit the inspector did not have opportunity to speak with relatives and other professionals. What the service does well: The home has a team of enthusiastic staff who have a good knowledge of the needs of the people in their care. Observations revealed positive relationships between staff and service users. Members of staff actively encourage service users to take responsibility for as many things are they are able, within their individual capabilities. There is evidence of service users receiving regular health checks and monitoring, and records are maintained. Staff at the home seek input from other health and social care professionals to assist in meeting individual need. A choice of food is available depending on the personal preferences of service users. The home provides a range of comfortable, safe and accessible shared space, which meets the assessed needs of the service users. Facilities available in the home consist of an allotment, sensory garden, sensory lounge, an indoor and outdoor keep fit area, punch bag and running machine, each bungalow has two lounges. The daycentre also has facilities for cooking and sensory massage as well as a second sensory room, quiet lounge and large area for craftwork and music sessions. Some redecoration of the bungalows has taken place since the inspection in January 2005, as required. Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) N/A None of these standards were assessed at this inspection. EVIDENCE: Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 The care planning and risk assessment records do not present information in a user-friendly format; this makes it difficult for staff to easily access the information they need to satisfactorily meet service users needs. EVIDENCE: The care plan of one service user was sampled in each of the bungalows. The majority of plans had been reviewed within the last six months, but some guidelines were undated. Guidelines must be dated on production to guide staff as to when they require review. Whilst the care plans sampled were detailed in content the vast array of information was often duplicated making it difficult to easily access information. The issue of duplication was raised at the last inspection. Service user risk assessments were sampled and were up to date. As identified with the care plans there was some duplication of information. Records should be organised better to ensure that all staff are aware of the risks to individuals and how these should be managed. Each risk assessment should be directly cross-referenced to the element(s) of the care plan to which it relates, and vice versa, so that the reader is naturally directed from one to the other. One of the outcomes for completing risk assessments and care plans should be that the Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 10 finished article is a simple and effective working document, in which essential information can be easily found. Due to the large number of risk assessments in place it is suggested that an index of all the risk assessments is included in the file, this should speed up the process of locating a specific assessment. Discussion with the team leader in bungalow two indicates that he is currently leading the process to update the care planning system. He stated that a new care planning system is to be introduced and that some work has commenced to cross reference risk assessments to care plans. Staff are also working with the Speech and Language Therapist to develop ‘Communication Passports’ for individuals. This is a document that will guide staff on the communication methods used by individuals. From sampling service users records, talking to staff and from observations made it is evident that service users are supported as much as possible to make decisions about their day–to-day lives. Any limitations on choice to prevent self-harm are clearly documented and appear to be made in the best interests of service users. Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 17 Service users enjoy a healthy and nutritious diet and exercise choice about what they eat. EVIDENCE: The menus indicated that a variety of food is provided and alternatives are offered. Service user records sampled contained detailed information on the food preferences of the individual. Stocks of food were adequate and included supplies of fresh fruit. Opened food in the fridge was date labelled to ensure it is consumed or discarded within appropriate timescales. Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20 The health needs of service users are well met. The systems for the administration of medication are generally good with clear and comprehensive arrangements being in place to ensure service users receive the medication they need. EVIDENCE: Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 13 There appropriate, referrals are made to other health professionals including the psychiatrist, psychologist, community nurse, occupational therapist and speech and language therapist. For one service user, psychology review meetings are currently being held on weekly basis, minutes of these meetings were available. Records held in the bungalows evidenced that service users receive regular health monitoring to include GP and dental input. Records were not available in the bungalows to evidence that service users had input from the optician. Staff spoken with were unsure of the dates of visits from the opticians. However, records of a recent optician visit were available in the main office. It is recommended that the dates of these visits is recorded in the individuals file in the bungalow so that health information is located in one file. Some service users are at risk from epileptic seizures. One sampled file contained clear guidance for staff on the action they should take in the event of a seizure occurring. Service users do not have individual health action plans. This is something that the Government paper, ‘Valuing People’ recommended that each person with a learning disability had by 2005. This is to ensure individuals receive all the care they need to stay healthy. However, the home is working towards the introduction of health action plans. The minutes of a senior staff meeting in February recorded a discussion on their introduction and the home has now obtained a template document that staff intend to complete for individuals. The medication administration systems were sampled in each of the bungalows. A local pharmacist supplies the medication to the home using the Nomad system. The pharmacist visits the home every three months to complete an audit of the medication. Some requirements were made at the last inspection with regard to the stock control systems and protocols for ‘as required’ medication. These were satisfactory at this inspection. Whilst the medication system is generally satisfactory in one bungalow three topical creams were opened but undated. One had been in dispensed in November 2004. Topical creams and ointments must be dated on opening and then discarded within 28 days. Evidence was available that service users have regular medication reviews. Some staff have completed the accredited ‘Safe Handling of Medicines’ course and several more staff are due to complete this in the near future. Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home has a satisfactory complaints system. The recording of physical intervention and reporting of incidents to the CSCI requires improvement to ensure they do not impact on the homes ability to protect service users from abuse and that their welfare is being promoted. EVIDENCE: The complaints procedure was not sampled at this inspection. At the inspection in January 2005 it was assessed as including all the relevant and required information and was produced in an accessible format for service users. The Deputy Manager stated that no complaints had been received by the home since the last inspection. The Service Users needs are such that the organisation provides the staff team with ‘breakaway’ training. It was required at the inspection in January 2005 that some staff required updated training in Studio III and managing behaviour. Several staff have since attended update training with the remaining staff booked to attend this training in October. A casual member of staff spoken with demonstrated good knowledge on the use of physical intervention, describing low arousal approaches and that physical intervention is used only as a last resort. Discussion with the Deputy Manager indicates that not all agency staff working in the home are trained in the use of physical intervention. The Manager must ensure that agency staff used by the home have the right experience, skills and training for the role they are undertaking. The home does complete incident forms and a monthly log of the number of incidents to include if physical intervention was used. However records on the use of physical intervention require improvement to ensure they meet the Department of Health guidance for restrictive physical interventions (2002). To meet the guidelines a book with numbered pages should be used and record Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 15 the names of the staff involved, the reason that physical intervention was used rather than another strategy, type of physical intervention, date and duration, if the service user or anyone else experienced injury. It is also recommended that following an incident both staff and service users should be given separate opportunities to talk about what has happened in a calm and safe environment. Records sampled and discussions with staff evidence that the CSCI has not been notified of accidents and incidents to include physical intervention as required by regulation. Guidance was given to the Deputy Manager on the type of notifications to be sent to the CSCI. Staff at the home have received basic prevention of abuse training, the Deputy Manager stated that further training had been booked for the end of July. Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 16 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 standard(s) 24, 28, 29 and 30 The standard of the environment within this home is generally satisfactory. It is comfortable but not always homely in style due to the needs of service users. Planning for the future refurbishment of kitchens needs to take place. EVIDENCE: Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 17 The home provides a range of comfortable, safe and accessible shared space, which meets the assessed needs of the service users. Facilities available in the home consist of an allotment, sensory garden, sensory lounge, an indoor and outdoor keep fit area, punch bag and running machine, each bungalow has two lounges. The daycentre also has facilities for cooking and sensory massage as well as a second sensory room, quiet lounge and large area for craftwork and music sessions. Staff facilities within each bungalow include an office and a room for the storage of personal belongings. Decorations around each of the bungalows are sparse in some areas but discussions with staff indicates this reflects the needs of the service users. In some areas furnishings had been slowly reintroduced into rooms, as service users were able to tolerate these. Furniture in both bungalows appeared to be of reasonable quality, comfortable and suitable to the needs of service users. Some refurbishment has taken place since the inspection in January 2005, as required. This includes redecoration of a service user’s bedroom in bungalow one and repainting of lounges and hallways in both bungalows. A section of carpet has also been replaced in bungalow one. Further work was identified at this inspection as being required. One bathroom in bungalow one was observed to have some discolouration to the ceiling and will require repainting. In bungalow two the kitchen ceiling requires repainting. The organisation will also need to plan for future kitchen refurbishments as units, worktops and décor are becoming worn. Requirements from the previous inspection included the provision of window coverings in one of the bathrooms. Coverings at windows continue to be an issue. Several windows in both bungalows were without curtains or blinds. Discussion with staff indicates that some service users will not tolerate curtains/blinds. The Manager must ensure a full audit of windows is completed to ensure that where there are no curtains/blinds measures are in place to ensure the privacy of service users. The home provides environmental adaptations to meet the assessed needs of the service users. These include the widening of steps, electrical socket protectors, décor in neutral colours with a matt finish, tactile symbols and pictorial aids that are provided throughout the bungalows. In addition to this staff are also provided with emergency call buttons and two way radios for summoning assistance. On the day of this inspection the home was clean, hygienic and free from offensive odours. Each bungalow has a laundry area, which is separate to the kitchen. The facilities are large enough to accommodate industrial sized washing and drying machines. The washing machines allow for soiled items to be washed at appropriate temperatures. The bungalows also have sluicing facilities. Protective clothing was seen to be available, including aprons and gloves. Clinical waste bins are situated in the bathroom areas. Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 and 35 The staff have a good understanding of the service users support needs. Staffing levels are appropriate to ensure service users are supported by sufficient numbers of staff to meet their needs. There is a continuous training programme in place for staff, and this should be developed further in accordance with service users’ assessed needs. Staff records require improvement to evidence that service users are being safeguarded by satisfactory recruitment procedures. EVIDENCE: It was noted that both staff and service users appear comfortable in each other’s company and enjoy a good general rapport. Members of staff demonstrate that they have a good personal knowledge of the individuals in their care. Staff spoken with were enthusiastic in their approach and welcomed the inspection process. Each bungalow operates with three staff per day shift, and three staff covering both bungalows over night. The staffing ratios at the time of this inspection were seen to reflect this. In addition, two service users have 1:1 support due to their high level of need. Previously this support has been provided by agency staff but for one individual a team of three permanent staff have been recruited. Support for one service user is still being provided by agency staff. As previously stated in Standard 23 the Manager must ensure that agency staff used by the home have the right experience, skills and training for the role Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 19 they are undertaking. This includes training in physical intervention and managing challenging behaviour. The records of three members of staff were sampled, two of whom had recently been recruited. Discussion with the Deputy Manager indicates that the home intends to improve the format of staff files. The home has a checklist of contents to work towards and intend to introduce a colour code system to enable speedier access to different sections within the file. Records on CRB checks needed improvement. For the long term member of staff there was no CRB information. For the two new staff there was a CRB disclosure number but the disclosure form was not available. CSCI inspectors are eligible to see disclosures as part of their inspection as per section 124(6) of the Police Act 1997. Exceptions are made by the CRB to the normal code of practice rule that disclosures may be kept for a maximum of six months, care homes can retain the disclosure for twelve months. The Manager must ensure that staff records contain CRB information to evidence that service users are appropriately safeguarded by the home’s recruitment practice. One file of a new member of staff did not contain a record of induction. The Deputy Manger stated that the staff had completed a full induction but that the record of induction was in the possession of the member of staff. The home will need to ensure that completed induction records are retained in staff records. An induction timetable for a new member of staff was observed, this evidenced that new staff initially work as super-mummery and have the opportunity to spend time in the day centre and both bungalows. Staff receive training in manual handling, health and safety, food hygiene, first aid, epilepsy, autism and communication, sexuality, person centred planning, medication, TEACHH (its structure and importance for people with Autistic Spectrum Disorder) and fire safety. Some staff have received training in Studio III and managing behaviour and further training is arranged for October. Adult protection training is booked for the end of July. Sampled staff files did not all contain an up to date record of the training that staff had received. For one member of staff the file did not evidence recent fire training. However, the Deputy Manager was able to produce a computer record for this training. It was recommended at the inspection that a training matrix should be produced for the staff group as a whole, this would enable staff, management and CSCI inspectors to see what training staff had completed at a glance. Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Systems are in place to promote the health and safety of service users but some areas of risk had been overlooked. EVIDENCE: Fire records indicated that the fire equipment had been regularly tested by staff and serviced by an engineer. The home did not have records to evidence that fire drills are conducted. The Deputy Manager stated that due to the effect the fire alarms can have on some service users it had been agreed with the West Midlands Fire Service that drills do not have to be conducted. However there was no evidence of this agreement or risk assessment regarding this practice in place, an immediate requirement was made to rectify this. The Manager has since provided evidence to the CSCI that this issue has been discussed with the West Midlands Fire service. It was required at the January inspection that water temperatures are monitored on a monthly basis. This is to ensure that water is delivered at a safe temperature to reduce the risk of scalding to service users. Records observed recorded that temperatures had been monitored in April only. The Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 21 Manager must ensure this requirement is complied with to ensure the safety of service users. Some risk assessments were available in the bungalows for premises, COSHH and food safety but these were few in number and had not been regularly reviewed. The Manager must ensure the premises are fully assessed and risk assessments reviewed regularly. During the inspection it was observed that several slabs to the front and side of the bungalows had round holes in them where drain covers were missing. The Deputy Manager stated that she had not been aware of this until today and thought they might have been removed by a service user. An immediate requirement was made to reduce the risk. Sampling of records and discussion with staff indicates that incidents have taken place where staff have been injured by a service user. It is evident that the home is endeavouring to reduce the risks to staff by regular reviews, 1:1 support for the service user and additional training. However the number of incidents occurring is of concern. Staff at the home continue to work with the multi disciplinary team to resolve the issues. However, if there is no reduction in the number of incidents the home may have to consider if they can safely continue to accommodate the service user at the home. Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x 3 3 3 Standard No 11 12 13 14 15 16 17 x x x x x x 3 Standard No 31 32 33 34 35 36 Score x x 3 2 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gorse Farm Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard 6 6&9 6 Regulation 15 12(1) 15 13(4) 15 Requirement Service user guidelines must be dated and signed on production and kept under review. Risk assessments must cross reference to care plans and vice versa. The care plan system must be reviewed to ensure staff can easily access information, old records should be archived and duplication of information avoided. Health action plans must be introduced for all service users in line with the Government paper Valuing People. All topical creams and ointments must be dated on opening and discarded after 28 days. Records on the use of physical intervention require improvement to ensure they meet the Department of Health guidance for restrictive physical interventions (2002). Accidents/incidents to include the use of physical intervention must be notified to CSCI. Remaining staff (primarily casual Timescale for action 30/9/05 30/10/05 30/10/05 4. 19 12(1) 13(1 13(2) 30/11/05 5. 20 6. 23 12(1) 13(6,7,8) 30/7/05 Immediate requiremen t 30/9/05 7. 23 37 8. 23 & 35 12(1) 21/7/05 Immediate requiremen t 30/10/05 Page 24 Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 13(6,7,8) 9. 10. 24 24 23 (2) (b, c, d) 12(4)(a) 16(2)(c ) staff) to complete training in Studio III and Managing Behaviour. Original requirement date of 31/5/05. The Manager must ensure that agency staff used by the home have the right experience, skills and training for the role they are undertaking. Ceiling in kitchen in bungalow two and bathroom in bungalow one require repainting. The Manager must ensure a full audit of windows is completed to ensure that where there are no curtains/blinds measures are in place to ensure the privacy of service users. The organisation will need to plan for future kitchen refurbishments as units, worktops and décor are becoming worn. Schedule to be provided to CSCI. The manager must ensure that Criminal Records Bureau (CRB) disclosures are available for inspection by the CSCI. Outstanding requirement from 20/10/04 Risk assessments for the premises must be in place and reviewed regularly. Outstanding from inspection in January 2005. Slabs outsie of bungalow two have drainage holes that pose a potential trip hazard. Action must be taken to reduce risk. Water temperatures must be tested monthly and a record of these must be maintained. Outstanding from inspection in January 2005. The fire risk assessment requires further development to reflect agreement with West Midlands Fire Service that evacuation for 30/11/05 30/9/05 11. 24 23 (2) (b, c, d) 30/9/05 12. 34 13 (6)Schedu le 2 30/9/05 13. 42 14. 42 15. 42 13 (4) (a, b, c), HSWA 1992 13 (4) (a, b, c), HSWA 1992 13 (4) (a, b, c) 20/8/05 Immediate requiremen t 21/7/05 Immediate requiremen t 30/7/05 Immediate requiremen t 7/8/05 Immediate requiremen t Page 25 16. 42 13 (4) (a, b, c), HSWA 1992 Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 service users does not need to take place when conducting a fire drill. (Evidence of consultation with WMFS receiveved after inspection, states horizontal evacuation). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 9 Good Practice Recommendations Due to the large number of risk assessments in place it is suggested that an index of all the risk assessments is included in the file, this should speed up the process of locating a specific assessment. It is recommended that information regarding optician visits is stored in the bungalows instead of or in addition to the main office. Following the use of physical intervention a debrief session should be conducted with staff involved with a record kept. A training matrix should be produced for the staff group as a whole, this would enable staff, management and CSCI inspectors to see what training staff had completed at a glance. 2. 3. 4. 19 23 35 Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House 45-46 Stephenson Street Birmingham, B2 4UZ 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 Gorse Farm E54 S4534 Gorse Farm V240725 200705 Stage 4.doc Version 1.40 Page 27 - 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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