Inspection on 25/09/07 for Handley Drive

This inspection was carried out on 25th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Handley Drive 20/11/09

Handley Drive 15/11/06

Handley Drive 17/05/06

Handley Drive 26/01/06

Handley Drive 27/07/05

Handley Drive 11/03/05

Handley Drive 07/07/04

Handley Drive 16/02/04

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 08/07/2008.

CARE HOME ADULTS 18-65 Handley Drive 12 Handley Drive Brindley Ford Stoke-on-Trent Staffordshire ST8 7QZ Lead Inspector Ms Wendy Jones Key Unannounced Inspection 25th September 2007 15:00 Handley Drive DS0000028916.V338890.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 Handley Drive DS0000028916.V338890.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. Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Handley Drive Address 12 Handley Drive Brindley Ford Stoke-on-Trent Staffordshire ST8 7QZ 01782 517079 F/P ianhd.Clarke@swann.stoke.gov.uk 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) Stoke on Trent City Council Ian Clarke Care Home 11 Category(ies) of Dementia (3), Learning disability (11), Physical registration, with number disability (2) of places Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2006 Brief Description of the Service: Handley Drive is a residential home located on the outskirts of Stoke On Trent, Staffordshire, the home is owned by Stoke on Trent City Council. The home provides a service for adults of both genders who have a learning disability, Handley Drive is also registered to accommodate three service users suffering with dementia and two with a physically disability. The two-storey property was built in the 1960’s, providing eleven single occupancy bedrooms, located on both the ground and first floor, en suite facilities are not provided. Bathrooms and toilet areas are located throughout the home and are in close proximity to both communal areas and bedrooms. The property provides two group living areas, on the ground floor there is a lounge dining area and a separate large lounge and separate dining area. There are also three bedrooms, laundry, office and walk in shower area on the ground floor. On the first floor there are eight further bedrooms, one assisted bathroom, one unassisted bathroom and also a shower room. There is a lounge/diner/kitchenette, which is used as a daily living skills training facility. Service users also have access to a garden at the rear of the property; ramp access and a grab rail are in place from the patio entrance. The home is located in a residential area and is in keeping with the local community. Staffing is provided on a 24 hours basis to ensure the total supervision and support of service users. Service users have access to relevant healthcare services if and when required. The fee chargeable for the service at Handley Drive is not recorded in the Service User Guide. Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report of an inspection of Handley Drive a service that is operated By Stoke-on-Trent city council and provides for people who have learning disability. The inspection took place during September 2007 and consisted of pre inspection planning and an unannounced site visit on the 25th September 2007, which took place over a period of 5.5 hours during the late afternoon and evening. Information for the report was provided from the services own Annual Quality Assurance Assessment (AQAA); from a Statement of Purpose and a Service User Guide; from 2 health professional survey’s, 1 social workers survey; from 4 staff survey’s; 6 relative and 5 service users survey’s. Other information included inspection of care records, medication records, health plans, policies and procedures, fire safety records and other relevant documentation. Staff, management and residents were spoken to and a tour of the building undertaken. At the time of the site visit 11 service users were living at the home, one of whom was receiving short-term care. Since the site visit the manager has responded to the main points identified in this report, clarified any areas that needed it and has stated that all requirements have been met within the timescales given and most of the recommendations have been addressed. What the service does well: Handley Drive provides service users with a comfortable and safe living environment that is generally well maintained. Service users said, “Staff always treat me well and the home is usually fresh and clean,” “ I have my own room and keep a key to it,”” I can have my room how I like it, I like to have all my things around me.” The standard of care planning and record keeping is good and the service users are supported and encouraged to be actively involved in care planning and making decisions about their daily life. They are helped further with this by the services efforts to produce information in a format that is easier for the service user’s to understand. Relatives are very positive in the comments they make about the service saying, “They recognise the individual needs of each service user.” “ The service users are very well cared for happy.” “Our relative is very happy the service provides a caring and nurturing environment.” Service users have a range of opportunities to access social, recreational and occupational opportunities both in and out of the home. Service users said, “I have more activities now than I used to.” Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 6 In response to a question about how the service ensures it promotes equality and diversity the manager states in the AQAA. “All service users have holistic individual care plans, all service users have individual monthly meetings with their link worker to discuss issues. Policy and procedure are followed. Advocates are used as required, reviews take place, family input sought. Local church supports service users to access religion. Any different type of religious requirements can be catered for. Staff have received anti-discrimination practice training. Staff individual needs are catered for as and when required.” Records show that the service meets the health, medication and personal care needs of service users, this is confirmed from health professional survey’s and the comments received from relatives. Service users said if they had any concerns they know who to go to, and are sure that they will be listened to. All service users know who their key worker is, and a complaints procedure has been reproduced in a format that they can easily understand. The majority of staff have received training in areas that are required, and over 50 have a National Vocational Qualification (NVQ) at level 2 or are working towards it. The home is well managed with systems in place to ensure that the quality of the service is monitored and developed when deficits are found. The records show that service users views are sought and listened to. Policies and procedures are in place and some have been produced in a user friendly format. Health and Safety, fire safety and infection control matters have been addressed. What has improved since the last inspection? The manager states in the AQAA that the service has improved in a number of areas, “Service users have been asked to provide input into the service users guide which is in the process of being picture formatted. Improved communication with social work team, other professionals and advocacy services. Contracts have been put in place for all permanent service users. Care plans and other information regarding the individuals support has been made available in other formats suitable to meet the indivduals needs.” Also service users are having a greater say in what they do, and said thay had an increased choice and amount of activities to get involved with. It is also reported that, meals that are prepared by the cooks have been moved to the evening in the week so that people have more flexibility when they go out. Pictorial menus have been created, and service users are encouraged to help prepare their own breakfasts and lunches. Service users said “I can be as independent as I want to be, and staff will support me.” Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 7 The service has consulted with service users and changed the GP practice to receive a better service, and has reported that is has developed greater working relationships with health professionals to meet the needs of people and encourage independence in managing healthcare problems. Staff have received training in recognising and reporting suspected abuse. Fire safety work has nearly been completed. Service users have had bedrooms redecorated, they confirmed this during this site visit. Some refurbishment has taken place. 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. The summary of this inspection report can be made available in other formats on request. Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that they received relevant information about the service in a format they can easily understand, this ensures that they know what to expect. Prospective service users can also be sure that their care needs will be properly assessed and they are involved in this process, so that they can feel confident that the service can meet their needs. EVIDENCE: The service provides service users and prospective service users with information about the service they can expect at Handley Drive. A document called the Statement of Purpose explains what the service offers, how many staff they have, who can be admitted to the home and what things service users can do at the home, among other things. Another document called the service user guide, provides a summary of the statement of purpose, and gives more specific information for each individual service user, including the terms and conditions of their residency at the home. Since the last key inspection of this home, there has been work undertaken with service users to provide this information in a more user-friendly format, which includes a pictorial format. The manager has also informed us that both documents are now under review to ensure they are both up to date. Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 10 The staff said that all service users have a copy of the Service User Guide; this was discussed and confirmed with 3 service users. One said, “I keep my guide in my room and staff to talk to me about it.” One service user has been admitted to the service during the last few months prior to this site visit. They confirmed that they had been involved in an assessment and were informed and consulted about agreed future plans. The records show that the service and the relevant professional’s involved in the individual’s life had carried out a full assessment. The service user stated, “ I looked at a few home’s but chose to come here.” “ I have been okay while here, the staff are great and I get on with most people. They are helping me decide what I want to do in the future.” The manager has stated in the AQAA that more work is to be carried out on further improving the assessment documentation. Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that they are fully involved in and included in the planning and reviews of their care this ensures that they are able to have their say and take some ownership of the plans they have in place. EVIDENCE: Service users have copies of their care plans if they want them and said that they are involved with the planning and reviews of their care. One service user said “ I want to change some of my plans and have talked to my key worker about it, we will look at them again.” “ I no longer need a plan about my personal care as I am now independent, so this will be reviewed with my key worker.” The service is adopting a person centred model for care planning, this is to be introduced and staff have to receive training. The information is again provided in a format that is user-friendlier, in a written and pictorial format. Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 12 Reviews of care are carried out regularly, staff and service users confirmed that one to one meetings to discuss plans of care are usually held monthly. The service has made considerable efforts to ensure that service users are included and involved in the care planning process and have also, where possible invited support for them from independent advocacy services. Service users views are sought both informally through daily discussion and more formally through service user questionnaires, meetings and one to one key worker discussions. In the AQAA the manager states, “ service users are encouraged to take informed risks to enhance their lifestyles, this is carefully planned and risks are reduced as much as possible so that people can suceed.” And also states that there are plans for, “other formats to be looked into i.e. voice care plans. having a newsletter or through the internet to say what we are doing and achievments etc. further partnership working with providers around the city and divisional plans to create opportunities for service users around the city offering more choice and fulfillment.” Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 – 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is (excellent) This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that they will be supported to have an active social lifestyle and be supported to access employment, occupational and educational opportunities where possible. They can also be sure that they are fully involved in choosing what they want to do. Therefore developing their skills, exposing them to new experiences and promoting independence. EVIDENCE: Person centred plans contain information about the individuals hobbies, interests and preferred activities. A weekly timetable is then produced following discussion with the service user to provide a guide for the activities that are to be undertaken. A sample of the plans shows that service users are involved in range of activities for example in one day, one resident was involved in domestic type Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 14 activities, such as room cleaning, laundry and involved with the lunch time meal preparation. Three services users attend day care services for four days per week, another goes for one day; one service users has work experience/ voluntary work opportunities for 4 days’ per week, another service user goes to college for 3 days per week. Some service users have sessions at specialist day care facilities in the community; others are involved in events that are integrated in the local community. Although the service has it’s own transport, service users are supported to maintain their presence in the community by using public transport, and this also provides them with opportunities to become more independent. In the service user survey’s two service users said “ I can choose what I want to do during the day but am not always able to in the evening.” Another said, “I have a good social life, it’s much better than it was 12 months ago.” Others said, “ I can choose what I want to do and my key worker helps me.” During the site visit one resident discussed his lifestyle saying, “ I’m independent and have a lot of things I like to get involved with and I really enjoy my computer work. We have meetings with our key workers and also have meetings when we get together to talk about things we want to do.” Another resident said, “ I have a lot of things I like to do and my key worker helps me to plan how I can fit them in.” Service users also showed evidence of their involvement in education, and occupational activities as well as how they are supported to pursue their hobbies and interests. Records of service user meetings are displayed on the notice boards in the home. Service users said “ we are going to Abersoch for 3 days, and have been on another holiday this year.” Records confirmed that all those who wanted to have a holiday break had been supported to do so. Menu’s have been produced on picture cards these are on display in the lounge and can be found in the kitchen, monthly meetings are arranged where service users can discuss their meal and menu choices. Service users said, “ I can choose my meals, if there is something I don’t want I can have something else.” Records show what service users like and the staff team know their dislikes, there is also evidence that they are provided with an alternative to the main meal at every mealtime. This visit did not include a detailed inspection of the kitchen and dining room as some work was being carried out to repair the dining room floor. Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that they will be supported to identify what their health and personal care needs are, and to put in place action plans to ensure that these needs are met. This ensures that they are fully involved with decisions that are made about their health and personal care, therefore promoting autonomy and independence. EVIDENCE: Service users confirmed that their personal and health care needs are being met at the home. Records show that each individual has a health needs planner and health checklist, which is reviewed monthly with them. The emphasis is on identifying a need and ensuring that the appropriate action is taken to support the individual to resolve any difficulties and to receive appropriate treatment if necessary. Records show that service users are supported to attended health appointments such as dental and chiropody. There is evidence that the service works with relevant health professionals. Comments from one health professional state. “The service always seeks advice, respects the privacy and dignity of residents and always meet their Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 16 health care needs.” The manager reported that in consultation with service users they have changed the GP to get a better service. A thorough examination of medication records and systems in place for the safe handling, storage and administration of medication was carried out at this site visit. The current medication room is a rather cramped cupboard, which should be considered for review, as it doesn’t allow for easy management and record keeping of medication. This was discussed with the manager following the site visit. Since the last inspection visit the service has made efforts to ensure that their systems for the administration of medication are robust. There is evidence that this has been successful, with good record keeping systems in place, including a record of the medication received into the home, record of medication administered and returned to the pharmacy. A consent form has been created to confirm and evidence that service users have agreed to the medication they have been prescribed. Those service users who have been assessed as able to self medicate, have GP and service users consent forms in place. As recommended at the last key inspection the service has revised it’s homely remedies guidance and have individual protocols signed by the GP. Staff have receive medication training, this is confirmed from discussion with staff during the site visit, from the information received in the AQAA and from the training records provided during this site visit. Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that that the service has procedures in place that promote their rights and are there to protect them and any complaints will be dealt with properly and promptly. EVIDENCE: The information in the AQAA states, “service users are encouraged to make complaints if they wish to so that issues can be dealt with effectively, by the appropriate person and swiftly. When a service user makes a complaint their views and concerns are taken seriously and acted upon.” The service has also identified areas where it can improve in relation to Safeguarding and Vulnerable Adults issues by, “Involving service users in training so that they are more aware of their rights and how the VA policy works. To increase staff awareness into VA policy, complaints policy and procedure. And futher training to take place into new policy for safeguarding adults when it is produced.” 3 relatives confirmed in survey’s that they knew how to make a complaint if they needed to, and if they had complained it had been dealt with promptly. Of the 5 service users who sent in a survey’s, all said they knew who to go to if they weren’t happy and 4 said they knew how to make a complaint. During discussion with service users during the site visit, they said, “I have no problems here, if I do I can talk to any of the staff, my keyworker or the manager.” “ I can talk to the staff if I am worried about anything.” Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 18 No complaints have been made to us about this service in the last 12 months and no Safeguarding referrals have been made. The complaints policy and procedure is on display in the home, is included in the Statement of Purpose and Service User Guide and has been produced in a format that is user friendly using simple language and pictures where appropriate. Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28 and 30 Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that they will usually have sufficient personal or communal space to meet their needs. This encourages their independence and autonomy. EVIDENCE: The service is a two storey building set on a residential estate in the area of Brindley Ford, Stoke-on-Trent. The building is distinguishable from the ordinary housing stock in the area. At the last key inspection fire safety issues had been identified as a continuing issue for the home, following a fire safety inspection on 29 March 2007 areas of non-compliance with the new fire safety regulations were identified and a programme of work to resolve these issues had been started. The work has progressed and the majority of the work has now been completed. The manager reported that the outstanding work included full completion of the work to provide each resident with a suitable bedroom door lock. And has since Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 20 stated that this work is now complete with the exception of some fire safety signage. Following discussion with the fire safety officer he is satisfied with the progress made and the action the manager has taken to ensure service users safety and well-being. This has been confirmed in writing since the site visit. This visit did not include a detailed inspection of the environment. Information in the AQAA included comments that “all rooms are single and well decorated meeting the needs of the individual service user. Bathrooms are located near to service users bedrooms and meet the needs of the service users. Shared space is apporiate to the size of the building and the amount of people within the building, well decorated, comfortable and accessible. Staff training is in place to meet infection control and areas are designated within the home.” Service users are happy with their bedrooms, one said “I have my own key to my room, staff always knock on my door and wait to be asked in.” Another said, “ I have my room how I want it with all my photographs and things I like on the walls, I chose the colours in the room and my bed covers.” None of the bedrooms have en-suite facilities, the manager has noted in the AQAA, “new furniture needed, occupancy could be reduced to make better bedroom accommodation offering en-suite facilities.” This would be beneficial particularly as some bedrooms are considerably smaller than others. All areas seen appeared to be clean and free from offensive odours. The front door to the service has a note displayed for staff to ensure that the door is closed properly, during this visit the door handle did not appear to be fully functional, which meant that the door wasn’t locking properly. This was bought to the attention of the person in charge. We have been informed by the manager that this has now been dealt with. Staff discussed the garden areas of the home and specific problems with a tarmac area that is uneven therefore considered to place service users at risk. It is a shame that this area hasn’t been made into a suitable useable space, this should be considered. One member of staff said that there are problems with the outside drainage, which means that water does not drain away properly. The area identified is outside the staff sleep in room, and is reported to cause staff to have a disturbed night. This matter has been reported to the estates department of the City Council but has not been resolved promptly; again this should be attended to. The manager has again informed us that this work has been carried out since the site visit. Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36.Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that their care needs will be met by a skilled and well trained staff team, who receive regular supervision and meet frequently to discuss individual needs. But staff are working additional hours to maintain appropriate levels of staff due to staff vacancies. EVIDENCE: In the AQAA the manager has stated that, “the staff are very dedicated to the service at Handley Drive and are passionate about supporting the service users. They are a consistent team with little turn over in staff, which increases the continuity and consistency of support. They are very experienced and have varying backgrounds of expertise able to meet the different needs of the individuals. They have excellent relationships with the service users, and linkworkers work particulary closely with the service users they are allocated to, and their family/friends.” The AQAA also states that the average weekly care and management hours equate to 390hrs, with additional ancillary staff. Staffing levels are maintained to provide adequate numbers of staff per shift to meet the needs of service users. The rota shows that at least one manager is avaiable during the waking day from 7.30am to 10.30pm and also provides Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 22 sleep in cover at night. The care managers hours are usually additional to this. Care staff are usually available, two per shift for the same period although this can vary dependent on the needs of service users, additional hours are also provided at peak times. It was clear from the staff rota that the staffing levels are reduced at the weekends, this is probably due to the fact that college and day services are not open. But it could also limit the amount of activity service users can enjoy at the weekends also. In addition staff sickness and vacancies have been identified as issues and evidence in the staff rota showed that this has stretched the resources of the staff team. Some staff were noted to cover additonal hours on a regular basis. In staff survey’s comments included, “ too much overtime is expected over too many day’s.” Staff training records show that all staff have received fire safety and health and safety training, all except 1 have received Manual Handling training and infection control. 6 need basic food hygiene and 2 need to attend Vulnerable Adults training. 7 staff have trained to National Vocational Qualification (NVQ) level 2, with 3 others waiting to either complete or to be nominated for the training. One manager has completed NVQ level 3, two are taking the qualification and one other is waiting to be enrolled. The manager and the deputy manager are undertaking the A1 assessors course, which means they will be able to assess those staff undertaking NVQ training, 6 of the managers have completed a health and safety for managers course, which includes risk assessment training. All managers have completed a safe handling in medication course reported to be compliant with the guidance set out in the Safe Medication Management for care homes and SKILS for Care guidance. All managers who need it have received training in IT, and 6 staff have completed a dementia-training course. It is important that staff have the skills and training to feel confident in the role they have to undertake. One member of staff stated in the survey, “ we had one service user who had mental health needs. We didn’t have any training for this and I found it very difficult.” The service must ensure that staff have the skills and knowledge to meet all of the needs of service users. Other surveys’ stated that staff are satisfied with the training they receive. The service provides individual staff with regular 1:1 supervision sessions and additional Personal Development Reviews. Staff confirmed this in the survey’s they returned prior to this visit. One staff said “ every 4-6 weeks my support and supervision is carried out with the unit manager.” Others said they regularly met with a manager to discuss how they were working. In addition monthly team meetings are planned but the records show these don’t always take place this frequently. During this visit access to the recruitment records of staff wasn’t available. Previous inspections have found the records to be satisfactory, the manager stated in the AQAA that “all checks are carried out and close liasion with HR Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 23 ensures that checks are in place and fair recruitment and selction is carried out. Personal development reviews take place to identify individual needs.” Information in the AQAA indicates that no new staff have been recruited in the last 12 months and staff have said in their survey’s that checks were carried out before they started to work at the home. Staff surveys also confirmed that the induction to the home is generally satisfactory. One staff said, “ I was very impressed with my induction, I felt the manager and deputy manager covered all issues well with me.,” two other staff said that the induction covered everything they needed to know. One said, “ the induction mostly covered everything I needed to know, but some managers gave conflicting advice.” Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 24 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, 39, 40 and 42 Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that the service is well managed and their health and welfare is promoted by the good practice of the home, this promotes confidence in the ability of the service to meet their needs. EVIDENCE: The manager has a number of years experience as a registered care manager in a number of settings, he has reported that he has completed the Registered care Managers award and NVQ level 4 in care. There is also evidence that he has undertaken other training to ensure that he is up to date with current trends and events, and can cascade this information to his team if necessary. Staff reported in the surveys that “the manager is supportive and always looking for courses to keep staff up to date.” A sample of health and safety records show that fire safety checks are undertaken, fire drills are carried out regularly, but some staff need to attend Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 25 another fire drill as some had only been involved in one this year, the recommended minimum is for two drills per year to ensure that staff know how to evacuate the building safely and quickly in the event of a fire. Fire training records are up to date. A fire safety risk assessment has been produced, with an emergency contingency plan in the event the home becomes uninhabitable. A commissioning certificate is in place as evidence that the fire safety system complies with the new fire safety regulations. Portable appliance testing has been carried out. The information in the AQAA states that health and safety training has been provided for staff including COSHH. Records show that policies and procedures are in place and some have been subject to review recently but others have not been for some time. The manager has shown commitment to service users by supporting changes to some relevant policies and procedures in a format they can more easily understand. There is also evidence that service user views of how the service operates have been sought in the form of questionnaires, and the manager has stated in the AQAA that he encourages service users and staff to comment and make suggestions about improving practice in the home. There is also some evidence that monthly visits to the home are undertaken on behalf of the City Council to monitor it’s performance and conduct, written record of these visits are maintained in the home and made available to us. The manager has also stated that he is actively involved in the discussions about the future of the service as the City Council is currently undertaking a review of the future of all residential services in the area. Quality audits are carried out in a number of areas and the manager has evidence that he has made changes where these audits have identified areas of deficit. He intends to use the information collected to inform a development plan for the service. Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 x 27 x 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 2 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 3 3 x LIFESTYLES Standard No Score 11 4 12 4 13 4 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 X 3 3 X 3 X Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 YA33 Regulation 18 Requirement Timescale for action 24/12/07 2. YA32 13(3)(5) Recruitment must be improved to ensure that staff are provided in sufficient numbers to meet the needs of service users, without existing staff working additional hours on a regular basis. All staff must receive mandatory 24/12/07 training in this instance manual handling and infection control. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA32 YA6 Good Practice Recommendations All staff should have training in the proposed PCP system. Consideration should be given in providing care plans in larger print to assist individuals who may have a visual impairment. Work should be undertaken to improve the tarmac patio area, for the benefit and use of service users. 3. YA24 Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 28 4. 5. YA36 YA20 More frequent staff meetings should be arranged. Consider a review of the current storage arrangement of the medication cupboards. Handley Drive DS0000028916.V338890.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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. 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