Inspection on 25/04/08 for Hall Bank Mews

This inspection was carried out on 25th April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Pontesbury Surgery Hall Bank Pontesbury Shropshire SY5 0RF Lead Inspector Deborah Sharman Key Unannounced Inspection 25th April 2008 09:00 Pontesbury Surgery DS0000071051.V363770.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 Pontesbury Surgery DS0000071051.V363770.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. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pontesbury Surgery Address Hall Bank Pontesbury Shropshire SY5 0RF 01743 872 250 01743 874 815 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) Condover College Sandra Julie Crump Care Home 10 Category(ies) of Learning disability (10), Physical disability (10) registration, with number of places Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only Care Home Only - Code PC To service users of the following gender Either Whose service users on admission to the home are within the following categories: Learning Disability (LD) 10 Physical Disability (PD) 10 The maximum number of service users to be accommodated is 10. 2. Date of last inspection This is the first inspection. Brief Description of the Service: Pontesbury ‘Surgery’ is a detached property that has been converted for purpose from a building which was previously the Doctors surgery. The building is divided into 3 houses, known as numbers 1, 2 and 3. There are eight bedrooms on the ground floor. Five of these are in ‘house 1’ and three are in ‘house 2’. House 3 is on the first floor and is home to 2 people who are mobile as there is no passenger lift. The ground floor is wheelchair accessible and when complete, it is hoped that external garden space will be more readily accessible for use by people using wheelchairs. There are ten bedrooms so each person living there is afforded a personalised room of their own with spacious en suite facilities equipped with either a bath or shower as chosen by the occupant. Each person who needs it has overhead tracking hoists that run between the bed and the en suite. Each bedroom has a TV aerial and internet access, a lock and a call bell. Telephone lines could be installed in individual bedrooms. A small lounge area is enhanced by an adjacent conservatory, which provides more communal space and light. Pontesbury is in a rural area on the outskirts of Shrewsbury. It has a village feel and staff and managers are pleased with how warmly they have been welcomed by the local community. Weekly fees range from £800.00 to £2200.00. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality Rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. Two Inspectors carried out this unannounced key inspection between 9.00 am and 6.00 pm. As the inspection visit was unannounced this means that no one associated with the home received prior notification and were therefore unable to prepare. As it was a key inspection the plan was to assess all National Minimum Standards defined by the Commission for Social Care Inspection as ‘key’. These are the National Standards, which significantly affect the experiences of care for people living at the home. Information about the performance of the home was sought and collated in a number of ways. Prior to inspection the Commission for Social Care Inspection was provided with written information and data about the home in an annual return. We compared this to information we had learned about the home during the application stages and registering process. During the course of the inspection we used a variety of methods to make a judgement about how service users are cared for. A Team Leader was on duty when we arrived and she showed us round and answered questions primarily about the moving in process and the environment. A Director and the Manager (who had been on a day off) joined us later and supported the rest of the inspection day. It is currently our policy not to send surveys to relatives and as many live at a distance we were not able to speak to relatives on the day of inspection. However access to minutes of a review meeting gave us some insight into how satisfied a relative was with the transition to Pontesbury Surgery. On the day of inspection we distributed surveys to staff on duty, which we took away with us to analyse, and we also had the opportunity to speak to most staff (5) on duty during the inspection. The Inspector assessed the care provided to two people using care documentation and we sampled a variety of other documentation related to the management of the care home such as training, recruitment, staff supervision, accidents and complaints. We toured the premises and we were able to observe the care of residents during this time. All this information helped to determine a judgement about the quality of care the home provides. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 6 The Chief Executive joined us at the end of the day for feedback. What the service does well: What has improved since the last inspection? What they could do better: Detail in care plans and in risk assessments is generally good. This helps staff to know how to provide care in a safe manner that is acceptable to people living there. Staff said they find care plans to be helpful and clear and risk Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 7 assessments to be self-explanatory. We found some anomalies however which need to be addressed to support consistently good outcomes for all service users. For example comparing one persons care plan with the outcomes of discussions with staff showed there are some contradictions and disagreement about the persons need and how to meet the need. This lead us to conclude that although there are some areas of good practice, there is scope for improvement in terms of how culturally diverse needs are met. Also risk assessments and safety maintenance checks in place did not reflect concerns we identified about the safety and suitability of two bedrails. We felt that the level of activities and access to the community could improve and of the two people whose care was looked at in detail, outcomes for the one person were better than for the other, although the frequency and range of activity and community access could improve for both. We were told that health had restricted opportunities for one person in the evenings, but we found insufficient evidence of activity at weekends as well. Staff were vague about what activities were planned for the afternoon and the planner on the wall was too general to guide staff sufficiently. Staff feel that staffing levels are ‘just manageable’ and that staffing levels combined with transport duties limit some opportunities for service users. The Manager told us now ‘that there is only one full-time vacancy, bank staff can be used to increase activities at Pontesbury Surgery, particularly at weekends.’ The provider states that they provide staffing levels in excess of the Department of Health guidelines, meeting those set out at the time of registration. Medication systems are developed and there is much positive practice. Two matters came to our attention however, that require improvement. Recent regulatory changes mean that the home must review how it is storing its controlled drugs. Secondly, we identified an issue with stock control for one prescribed medication belonging to one of the two service users whose care we tracked. Although the medications had been signed as given, anomalies in stock control cannot assure that the medications have been given as signed for and therefore that the service user has received medications as prescribed. The audit trail must tally clearly and accurately from the time when medications are received onto the premises. Managers agreed to investigate this. There have been no allegations, incidents or complaints since the service opened. Training is provided to staff to help them to identify abuse and to respond accordingly and procedures are in place to support this also. We discussed with the provider how the policies could be improved. Through discussion we also brought to the providers attention how historical practices such as the use of helmets and restrictive pyjamas could be defined as restraint and should be fully reviewed with Social Services and comprehensively recorded. The provider states they are ‘careful’ in their use of these items, but we feel that such measures should be formalised and evidenced more robustly. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 8 The need to improve some aspects of infection control was the primary issue we identified from a tour of the environment namely in respect of laundry practices. Staff have a mostly good understanding of service users needs, present as motivated and keen to do their best for the people who live there. They describe themselves as a cohesive and effective team and describe managers as ‘approachable’. A lot has changed for them and there are clearly some matters affecting them which they still feel need to be resolved – ‘little grumbles’ about how ideas are received by management, not feeling systems are in place to help them to participate fully in the weekly staff meetings and some resentment about being ‘classroom assistants’ at Grafton where they support day education. They also reported concerns about inaccuracies in wages. They assessed the management of the home as ‘adequate’ and ‘almost good’, reporting that required improvements were not affecting service users but recognised that happy staff positively affect service users. 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. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 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 Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. A period of consultation identified those who would benefit most from moving and needs and friendship groups along with the views of relatives were considered. Service users were involved in the practical aspects associated with moving house. This has enabled people who have moved into Pontesbury Surgery to settle into their new home well This judgement has been made using available evidence including a visit to this service. EVIDENCE: Eight of the nine people who now live at Pontesbury Surgery moved there in a planned move from Condover College as part of the provider’s development strategy. Therefore the provider who manages both Condover College and now Pontesbury Surgery knows the eight service users well, having cared for some of them for a number of years. A series of questionnaires, discussions with relatives and funding authorities and consideration of need and friendship groups helped to identify those who would benefit from moving. Service users became involved in the latter stages of the move and visited the premises when it was safe to do so when the majority of renovations were complete. The provider was working to a tight time scale and therefore people moved in very shortly after the service was registered, leaving no time for overnight stays and gradual introductory stays after registration. People were involved Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 11 in choosing colour schemes and shopping for their bedrooms however and they are individualised. As the move took place after the introduction of the Mental Capacity Act, it would have been excellent if peoples mental capacity had been assessed in relation to their ability to decide to move and had advocates worked to represent each individual during this process. However, service users seem to have settled well. Admissions procedures had been followed for the service user who was admitted to Pontesbury directly from home and the service thoroughly assessed her needs several weeks before she moved in. Records report a relative to have said that ‘the transition from home to Pontesbury and Grafton had been successfully achieved in a short time’. Furthermore, although another service user we spoke to was unable to say why, she clearly said that she was happy with the move to Pontesbury and that it is ‘better’. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is adequate as we found service user experiences to differ. We identified some areas of uncertainty and contradiction especially in relation to diversity, which are affecting outcomes for one service user whose care we looked at. We are satisfied however that the service has the ability to address these issues. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff find care plans and risk assessments to be useful, clear and self explanatory. We found care plans to cover most areas of assessed need, strengths, goals and aspirations and to have been reviewed and updated. We advised that more detail should be included in a care plan to guide the steps, limits and involvement of staff in gastronomy care. Photographic illustrations are available in the care plan where this is easier to follow than written instructions. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 13 Gender care is well represented in care plan guidance and care required to enhance female service users self esteem and sense of their femininity is recognised. Care planning designed to meet a service user’s specific cultural requirements however contradicted what staff told us. Therefore we found uncertainties about diet, language identity and dress. This service user’s opportunities are affected by regular behaviours that challenge. As the care plan guidance for this centres on communication, it is vital that an effective means of communication for her is identified although we were told that a worker is using flash cards and her vocabulary of English words is improving. Although this person is bi lingual and was placed at the home on the basis of being able to communicate in English, there’s little opportunity at the moment for her at home to maintain her use of a language used by her community and part of her family. Staff are keen to address this however and have approached a social worker, we were told for help. We were initially told that staff do not know how to support the service user to wear the traditional dress available. Further inspection shows one staff member to be practicing techniques at home. All staff who provide personal care should be supported to be able to enable this resident to wear her cultural costume. Discussion with staff shows them to be committed to meeting service users cultural needs. Service users have profound needs and there is good guidance in care plans about how they are able to make choices when they cannot do so verbally. Minutes of residents meetings are positive to read as they demonstrate that staff are aware of how residents indicate choices as their non-verbal responses are noted e.g. ‘X smiled’ and ‘Y blew a kiss’. Review meetings have also been held and staff write a report to inform the review of key issues. One such report tells us that initially there were a few health issues but that ‘on each occasion we have sought advice from Doctors, parents and the dietician. We now have protocols and regimes in place’. Risk assessments are in place for a range of hazards and moving and handling risk assessments are well written. The integrity of the bedrail risk assessments and checks were queried. They were found not to reflect risks identified from looking at two peoples bedrails where we found unstable rails and large gaps between the mattresses and rails risking limb entrapment particularly during epileptic seizure. The Managers undertook to address this without delay and have confirmed to us in writing actions being taken. Nobody currently has pressure sores and managers felt that no one is at risk of skin breakdown. We advised that risk to service users skin integrity is assessed given the levels of many service users physical dependency. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 14 Financial risk assessments and deprivation of liberty assessments would when carried out also seek to promote service users interests. Large equipment to reduce moving and handling risk has been provided and physiotherapy advice has been obtained. The Home would benefit from OT advice on risk-taking and aids to minimise risks and to further develop some residents independence with for example, a kettle aid. This was observed to affect the extent to which one mobile individual with epilepsy participated in making a cup of tea, which stopped short of using the kettle. We observed a resident living in the flat to be drying up her breakfast things independently and taking pride in keeping the kitchen clean. We observed people being able to help themselves to fruit, without seeking permission, which is good practice. The service is committed to promoting independence. Pontesbury Surgery DS0000071051.V363770.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): 12, 13, 15, 16, 17. Quality in this outcome area is adequate. Outcomes were found to differ for people living at Pontesbury Surgery. Service users are supported to maintain contact with relatives and friends who often live at a distance. Opportunities could be further developed to ensure that service users enjoy a range of appropriate leisure activities and are part of their community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We found on the kitchen wall an up to date planner outlining which residents were going to educational opportunities and which were taking part in day opportunities and Independent Living. We asked staff what was planned for independent living skills that afternoon and responses were vague. Perusal of activity records for one service user for the first 24 days in April showed she had had her nails painted twice, had her legs and feet massaged, attended a memorial for a friend and had ‘been out on the van’. Other than this and Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 16 attendance at her education day setting there was no other evidence of community access for this period. Assessment of financial records supported our conclusion although these records told us she had also been to the pantomime back in January. Activity outcomes for a second service user were better as we could see she had been to Chester Zoo, a café, a garden centre and to McDonalds twice since moving in but we would not yet agree that ‘the residents have an active and full social life’ as described to us in the homes first annual return. We observed service users partaking in domestic tasks where they were able. Staff feel that staffing levels are restricting opportunities for service users. Appearing to recognise the need for some improvement, the Manager said that now that there is only one full-time vacancy, bank staff can be used to increase activities, particularly at weekends. Staff believe that current transport and lunch arrangements for those in education are inhibiting day opportunities for others and this should be kept under review. Written records show us that residents are supported to have contact with families, by phone and letter when they live at a distance and that staff keep in regular contact with families too. We observed a service user being supported to talk to a parent on the phone in the privacy of his bedroom enabled by staff. A service user who joined us for a tour of the environment was looking forward to the weekend when friends were invited to join her for a tea in celebration of her birthday. The service recognises service users’ sexuality and their associated rights. Specialist guidance was sought on behalf of a service user about an intimate issue. We found copious food provisions on the premises and service users told us that they enjoy the food. We observed a service user being supported to eat, later than others to fit in with his preferred routine. A complex feeding regime is managed well for one service user. We were told that people who are peg fed are encouraged to sit at the table with others for social contact although we did not see this at the time of inspection. People were observed to be able to take their drinks where they wished. There needs to be greater clarity about one service user’s dietary needs as although the care plan says ‘halal meat only’, staff said this was difficult to obtain and it wasn’t certain from discussion whether she requires a halal, kosher or vegetarian diet. There are no staff currently employed that reflect this service user’s heritage but discussion with staff showed them to be keen to address the areas of need and that work is underway to bring about improvements for this service user. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 17 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): 18, 19, 20. Quality in this outcome area is good. Residents’ personal care and health needs are complex. There have been no accidents or incidents and there is good evidence that staff liaise well with a range of health professionals and that this is positively impacting on service users health and well being. Medication management systems are well developed. This helped us to identify a problem in medication stock management, which made it difficult to reconcile how one service user had received one medication as prescribed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users have complex needs but we were told that no ones health is currently a cause for concern. Discussion with staff showed them to understand health needs generally very well. A number of service users are not mobile. We were told that no one has pressure sores or are at risk of pressure sores but we advised that this should be considered by way of a formal assessment of tissue viability. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 18 There is good evidence that peoples health is monitored and responded to and that there is good interagency working between the home and a range of health professionals. Only trained staff are involved in providing gastronomy care to one service user and the manager feels well supported in this by the hospital nursing team. Staff seek advice when it is required and health appointments are followed up well. Not all service users have received the full range of routine health screening appointments yet such as dental and optical checks for example but they are being re registered with new local practices and the aim is for them all to have received these checks within the first year of occupancy. Staff know service users’ personal care needs and preferences and they are supported with this in the privacy of the bedrooms. New staff told us that they received training in moving and handling before commencing work with service users. Equipment provided to support the safe moving and handling of residents is appropriate and there have not been any accidents or incidents. Appropriate medication cupboards have been provided and some steps taken to secure (and account for) controlled drugs but further steps are required to comply with the new 2007 regulations. Medications are not crushed or given covertly and we are assured that medications are being rarely used to manage behaviours. Such medications are available and are used exceptionally as prescribed when necessary in the service users best interests, only when authorised by a member of the senior team. Staff are signing medication administration records indicating that service users are receiving their medications as prescribed. However, an anomaly in accounting for one medication belonging to one service user whose records we sampled requires further investigation to assure us that this service user has been receiving her medication as prescribed and that stocks are being reliably managed. Managers undertook to investigate this and report their findings to us. Good systems are in place to account for medications that are removed and then returned to the home following periods of social leave. No one is currently self-administering medication and Managers agreed that a positive development would be to assess service users’ ability to do so. The home has at its disposal a pharmacist who has been supporting its sister home. The pharmacist has not undertaken any support visits to this new service yet, but we were told that this is possible and would be requested now. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 19 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): 22, 23. Quality in this outcome area is adequate. There have not been any incidents, allegations or complaints and managers know what action to take should any concerns come to light. We feel that service users are well cared for and are safe on a day to day basis. We feel however that further steps can be taken to address some risks and practice issues. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is much positive practice to report and the provider and staff are committed to safeguarding residents in their care. The needs of residents living at Pontesbury Surgery make them particularly vulnerable and it is important that, in light of new legislation that this area is continually reviewed and developed. It is positive that the Managers were able to recount actions they would take to safeguard people in the event of there being a concern. We are aware that although there have been no allegations at Pontesbury Surgery, the provider has experience of taking action to stamp out poor or abusive practice and understands the need to support staff who blow the whistle on poor practice. Training is provided to staff to help them to identify abuse and to know what to do. We spoke to a new member of staff appointed during the month of this inspection. She confirmed that she had already received such training. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 20 Meetings are held with residents and minutes showed us that staff have informed them of their right to be and feel safe and what to do should there be any shortcomings in this area. We also saw a creative system supplied to service users in their rooms where they could seek ‘help’ with a clever detachable sticker, although it is acknowledged that the format would not be able to be used by many service users. A range of policies are available and we advised how these could be improved particularly in relation to the implications of the Mental Capacity Act and the inter-relationships between the various policies. Mental Capacity Act training is planned and will address gaps in knowledge we identified in relation to the implications for practice of deprivation of liberty e.g. the use of door locks, lap straps, use of protective helmets and restrictive pyjamas. We found one service user to be wearing restrictive pyjamas to support the management of incontinence aids during the night, which we were told the service user accepted now but did not like at first. It is recommended the home completes a Deprivation of Liberty checklist, contacts Social Workers to agree findings and any care changes to ensure least restrictive options are used. Records indicate one service user presents challenging behaviours daily and sometimes several times daily. Policies and care plans advice distraction techniques and minimal physical interventions which is good but there could be greater clarity and more training provided in physical intervention, should the need arise. We were concerned that restrictions in communication from language barriers may be triggering the challenges. We advised that the support of a clinical psychologist be obtained to review this aspect of this persons care and that communication with this person be reviewed and improved. Accounts and records are available to justify service users expenditure. A staff member expressed concern that too many people have access to service users monies and had made suggestions for improving the systems. Other issues that came to our attention requiring intervention for improved protection of service users include: The provision of window restrictors based on an assessment of intruder risk. The need for consistency amongst team leaders in audits of service user finances as the quality and accuracy in records differed. The provision of safe bedrails and bumpers for service users. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 21 Improved maintenance checks and risk assessment systems for bedrails that accurately assess and reflect risks. The need to raise with social workers concerns that staff have about service users not benefiting from mobility cars run by families and other matters where there may be a conflict of financial interest. It is recommended that individual risk assessments re financial management be carried out to improve service users financial safeguards. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 22 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): 24, 30. Quality in this outcome area is good. Pontesbury surgery provides people who live there with clean, modern and homely living accommodation that has been equipped to meet their individual needs. Infection control systems require consideration to minimise the risk of service users and staff becoming ill. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the environment showed the premises to be clean and fresh, well maintained and homely with no evident obstructions or obvious hazards (other than those posed by bedrails referred to elsewhere in this report). Equipment used by residents previously has been replicated and discussion with staff indicated that the service is well resourced to help them to meet service users needs. Shortages identified shortly after moving in were met. Additional freezers and driers for the laundry were purchased to help the service to run smoothly and in service users best interests. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 23 Communal space is restricted currently as a leak in the conservatory roof is being explored. When repaired the intention is to change the use of the communal space to maximise that which is available. If this happens the living area will move into the conservatory and the dining area currently in the conservatory will move to the lounge, closer to the kitchen. Most but not all actions recommended at the time of registration have been acted upon. It remains (subject to approval from the Fire Authority) for a vision panel to be fitted to the laundry door to minimise the risk of opening the door onto somebody passing by in the corridor. Some window restrictors have been fitted to the ground floor on the basis of risk to service users from the windows. This needs to be reassessed based on the risk to service users of intruders accessing the property. A number of remedial actions are required to reduce the risk of infection namely in relation to the storage of clinical waste and laundry management. The storage of clinical waste outside whilst awaiting collection is not currently acceptable. Bins are not identified for purpose and could be confused with general refuse. None of the clinical waste bins outside are lockable and one in particular is at the front of the property and therefore could be accessed by visitors or other members of the public. The laundry is exceptionally small, without mechanical sluice facilities and given this, consideration should be given to how the risk of cross contamination will be reduced. We found for example clean linen stored and exposed within the small area where faecal matter is manually sluiced. We also found an internal broom used throughout the premises to be suspended inches above the manual sluice. Staff have little experience of laundry management as prior to the move to Pontesbury it had been contracted out. We were told that staff are beginning to identify these issues but that corrective action had not yet been taken. At the time of inspection, steps had been taken to clear overgrown trees and shrubs from the rear garden and plans have been drawn up to develop the front and rear external spaces. It is hoped that this will be completed by summer to enable service users to enjoy this additional communal space. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 24 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): 32, 33, 34, 35, 36. Quality in this outcome area is good. The staff team is cohesive and effective. Individual staff are well motivated and take pride in the service they provide. A lot has been achieved in a short time but there are some change management issues that require resolution to ensure that the team continues to be motivated and effective for the benefit of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Systems are in place to monitor training provided to both individual staff and the team as a whole and some training is booked to meet identified gaps in learning and knowledge. Discussion with staff showed them to feel well trained with one staff member telling us he had received ‘more training here than anywhere else’. Further discussion with a very new staff member also showed a wide range of training including induction to national standards to have been provided. A staff member employed for almost a year could also evidence having taken part in a wide range and number of appropriate training courses. Some training is provided in house and a lot is provided by external trainers, beyond the minimum, to help staff to meet service users specific needs and conditions. For example the physiotherapist provides postural Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 25 management training and this enables care staff to maintain service users exercise regimes. The epilepsy nurse provides epilepsy training. Staff who have transferred to this new project have undergone huge changes and are adapting to new ways of working. Staff describe the team as cohesive but would welcome the opportunity to influence the service more. They confirmed that weekly staff meetings are held but do not feel that these currently are a two way process. They feel that staffing levels are safe but limit service user opportunities. They feel that these in part are affected by the amount of their time that is committed to transporting some residents to their educational facilities including return trips to and from home at lunchtime. Staff expressed concern that new staff are sometimes included as part of the staffing ratio, adding that the rota is not clear and does not always accurately reflect staffing. We followed up concerns that staff raised. We found that there is room for the further improvement of leisure opportunities and share staff views that this could improve. We assessed staffing ratios against the levels described to us at the time of registration. Staffing levels complied with the homes statement of intent at the time of this unannounced inspection with 5 staff being on duty lead by a team leader who was in charge. We could also see from the rota that 5 staff are provided at other times and that staff are not working excessively long hours as they are supported by regular bank staff. Discussion with staff showed however that they felt there should be more permanent staff and less reliance on bank staff. The manager confirmed that an additional permanent staff member has been recruited subject to satisfactory checks and references. Since inspection the provider has confirmed that they provide staffing levels in excess of the Department of Health guidelines, meeting those set out at the time of registration. At this stage staffing levels are thought to be safe but should be kept under review. The rota shows us several areas of good practice. Where staffing levels reduced to 4, the reason is accounted for on the rota i.e. a resident was away on holiday with his family. It also demonstrates how a service user was to be supported to attend a one to one activity horse riding in an evening. Where shifts have been swapped this is recorded. Staff roles and responsibilities including mentoring new staff are included on the rota. However, on one occasion that we saw it did appear that a new staff member was part of the basic staffing ratio. We discussed this with the manager who explained that a staff member would have ‘moved across’ to ensure this didn’t happen, but the rota had not been amended to represent this. Also the manager now needs to ensure that she is included on the rota with her care and management hours clearly recorded and differentiated. Currently, the manager is only recording her absences on the rota. These improvements will ensure that staffing actually provided will be accounted for accurately. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 26 We looked at how two staff had been recruited - one permanent staff member and one staff member appointed to provide ‘bank’ cover as and when required. We were satisfied that procedures had been followed and that these staff had been safely recruited although photos are required for each on file. In occasional and exceptional circumstances especially to cover night shifts, staff are supplied by an agency. We have advised managers to review how they assure themselves that the agency has recruited staff robustly. They could do this by seeking assurance in respect of each staff member whose services they use as opposed to the general letter about the agency’s recruitment practice that they currently hold. Staff told us that they feel time and attention has been devoted to new staff, at their expense. Assessment of supervision records supports their view to some extent. It is commendable that new staff have received regular supervision but disappointing that another staff member transferring from Condover House to Pontesbury had not had a supervision for the majority of the time since the move. This was explained by a change in the management team and the need for time to adjust to the new role. The Manager described feeling well supported by the staff team and also described how quickly the new team had formed and become effective. It is important that change issues raised by staff as ‘little grumbles’ are worked through with them to enable the team to move forward and develop further in their and service users interests. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 27 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): 37, 38, 39, 41, 42. Quality in this outcome area is adequate. The management and staff teams have achieved a lot in a short period of time. There now needs to be a period of consolidation to enable all parties to clarify their roles and settle more fully into them. Managers are ensuring that the service is sufficiently safe but should now seek to address the issues identified for improvement and further develop the management approach within the home for the benefit of all. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The newly registered manager is appropriately qualified and has worked for the provider for twenty years. She has known the service users for a long time therefore and described them all as ‘remarkably well’. She said that the move to Pontesbury Surgery had been an exceptionally busy time as it was closely followed by Christmas but she feels that she is now settling into her Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 28 new role as manager. She has felt well supported by a cohesive staff team and is appreciative of the level of support she has received from her managers who are Directors of the service. She has had regular supervision and an appraisal and reported having at least weekly contact with her managers who have spent a lot of time on the premises. It was agreed that this now needs to be formalised in regulation 26 reports. Two team leaders, one of whom is new to role are available and have responsibility for an identified house, but in the absence of the other one of them assumes responsibility in the first instance for the whole service. Staff feel residents are safe and are well cared for. Discussion with staff and analysis of surveys they submitted to us indicates that staff are a little unsettled about a range of matters relating to their employment, roles and how they are enabled to influence the service. Staff are adamant that these matters are not affecting service users adversely but recognised that a happy staff team would positively impact on service users. All staff spoken to rated the management of the service as ‘adequate’ and ‘almost good’. A fire risk assessment is in place but states there is no one within the premises who has mental incapacity and this should be re looked at. Staff confirmed taking part in regular fire drills and fire safety training since moving in and were appraised of the evacuation plans. One in three staff we asked have undertaken infection control training, with the service’s annual return stating 48 have completed it in total. Given improvements identified as required in relation to infection control, this should now be prioritised for all staff. Up to date risk assessments relating to the environment generally and the management of hazardous substances are available. Hazardous products are stored safely away from service users. The laundry door opens into the corridor and could cause injury to any person in range. It was suggested at registration that a vision panel be fitted to the door. This has not been done. We did not assess service maintenance records on site as many had been submitted and accepted as part of the registration process within the previous six months. The risk of burns and scalds is minimised as low surface radiators are fitted and water outlet temperatures are monitored and fall within safe levels. Some window restrictors have been fitted but this should be reconsidered in light of intruder risk. A tour of the premises showed us that service user records are not being stored securely. They are being kept in an unlockable domestic sideboard in the lounge which is a communal and public area. Storage space is limited but managers undertook to review this to ensure that personal information about service users is held securely. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 29 The Provider has developed quality assurance systems, which as a new service are in their infancy at Pontesbury Surgery. The Manager takes part in devised systems to monitor quality but was unable to fully describe all the strategies in place. The Director of Care described these to us. However it is positive that surveys have been sent to residents asking for their feedback about their home. The results were not on the premises however and we look forward to seeing these at subsequent inspections. The home’s annual return was submitted as we requested although it is unusual to do so prior to a first inspection. It was completed to a reasonably good level although there were some cutting and pasting errors and information was general, largely based on the provider’s experiences with its sister home. It accept that it is difficult to complete fully so early in the life of a home and we look forward to seeing examples of practice specific to Pontesbury Surgery next time when it is a more established service. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 30 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 3 4 X 5 X 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 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 3 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 2 13 2 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 2 2 X 2 3 X Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? No. This is the first inspection. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA9 Regulation 13(4)(C) Requirement Steps must be taken to ensure that all bedrails in use are fitted and maintained safely in accordance with the Medicines and Healthcare Regulatory Agency (MHRA) December 2006 ‘Safe use of Bedrails’ guidance. This will ensure that unnecessary risks to the health or safety of service users are identified and as far as possible eliminated. Requirement arising from this inspection April 25 2008. Timescale for action 02/05/08 2 YA20 13(2) Controlled drugs must be stored 25/07/08 in a made for purpose controlled drugs cabinet and rag bolted to a solid wall in accordance with new regulations August 2007. This will ensure that the home complies with its regulatory duty and will minimise the risk of misappropriation of drugs that are controlled. Requirement arising from this inspection April 25 2008. 2 YA20 13(2) Medication stock management systems must be reviewed to DS0000071051.V363770.R01.S.doc 02/05/08 Pontesbury Surgery Version 5.2 Page 32 ensure that the home can account for all medicines received, administered and leaving the premises. This will ensure that the home is accountable for all medicines and can demonstrate that service users have received medication as prescribed to promote their health and well-being. Requirement arising from this inspection April 25 2008. 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 YA13 Good Practice Recommendations Steps should be taken to ensure that service users cultural needs are accurately assessed, known to staff and met in terms of diet, traditional dress, language, religious persuasion etc. Recommendation arising from this inspection April 25 2008. 2 YA13 Steps should be taken to further develop and extend leisure and community access opportunities for service users that accord with their assessed needs, wishes and interests. Recommendation arising from this inspection April 25 2008. 3 YA18 Steps should be taken to review whether there are any further domestic aids available that would support service users independence and control over their lives. Recommendation arising from this inspection April 25 2008. 4 YA19 Service users tissue viability should be assessed to ensure that any potential complications and problems can be identified and dealt with at an early stage. Recommendation arising from this inspection April 25 2008. 5 6 YA20 YA23 Assessments should be carried out to determine service users ability or potential to self administer medication. Recommendation arising from this inspection April 25 2008. Deprivation of Liberty assessments should be carried out in respect of service users where appropriate. The findings and any care changes should be agreed with social DS0000071051.V363770.R01.S.doc Version 5.2 Page 33 Pontesbury Surgery workers, ensuring the least restrictive options are used. Recommendation arising from this inspection April 25 2008. 7 YA23 The service user whose care was looked at in detail and who is presenting daily behaviour challenges should be referred to an appropriate specialist to try to reduce the service users need to present such behaviours. Recommendation arising from this inspection April 25 2008. 8 YA23 Risk assessments should be carried out for the management of individual service users finances. Current practice in the management and auditing of service users monies should be reviewed to ensure that it is fully complying with policy and procedures and is consistently being applied across all three houses. Recommendation arising from this inspection April 25 2008. 9 YA30 The storage of clinical waste should be reviewed to comply with good practice and reduce the risk of access in error. The risk of cross contamination from manual sluicing in the laundry should be assessed and steps taken to reduce any hazards identified. Recommendation arising from this inspection April 25 2008. 10 11 YA37 YA40 Regulation 26 visits should be formally carried out and recorded. Recommendation arising from this inspection April 25 2008. Steps should be taken to review the range of current safeguarding policies in light of the Mental Capacity Act and to ensure they fully cross reference, embed the principles of safeguarding and comply with recognised professional standards. E.g. To recognise the need to report to Government barring lists. To recognise that bullying and harassment includes service users rather than just staff. To recognising that abuse can include incidents between service users, friends and families. Recommendation arising from this inspection April 25 2008. 12 YA41 Arrangements for the storage of service users personal records should be reviewed to ensure that personal information is held securely and is not accessible to unauthorised people. Recommendation arising from this inspection April 25 2008. 13 YA41 The rota should evidence staff and managers on duty and should reflect all changes so it is an accurate representation of actual staffing arrangements. Recommendation arising from this inspection April 25 2008. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 34 14 YA42 Subject to approval from the Fire Service, the fitting of a vision panel to the laundry door should be considered to minimise the risk of injury to someone in range of the opening door in the corridor. Recommendation arising from this inspection April 25 2008. 15 YA42 The provision of window restrictors should be reviewed i.e. provided on the basis of assessed risk from intruders. Recommendation arising from this inspection April 25 2008. Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Pontesbury Surgery DS0000071051.V363770.R01.S.doc Version 5.2 Page 36 - 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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