Inspection on 24/10/06 for Heronsmede

This inspection was carried out on 24th October 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Heronsmede 23/10/08

Heronsmede 05/12/05

Heronsmede 05/07/05

Heronsmede 11/01/05

Heronsmede 14/10/04

Heronsmede 07/02/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Heronsmede 88 & 90 Straight Road Old Windsor Berkshire SL4 2RK Lead Inspector Stephen Webb Unannounced Inspection 24 October 2006 10:15 th DS0000011297.V308557.R02.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 DS0000011297.V308557.R02.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. DS0000011297.V308557.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heronsmede Address 88 & 90 Straight Road Old Windsor Berkshire SL4 2RK 01753 855694 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) Choice Limited Ms Susan Ann Still Care Home 8 Category(ies) of Learning disability (8) registration, with number of places DS0000011297.V308557.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th December 2005 Brief Description of the Service: Choice Ltd, an independent organisation, owns and manages Heronsmede which is a registered service offering personal care and accommodation for up to eight people, under the age of 65, who have a learning disability and associated challenging behaviour. The home is situated on a main road in Old Windsor with good access to local shops and amenities. Heronsmede is a detached house and bungalow that have been joined together by an extension to provide a variety of areas for residents to use. There is a large garden, mainly laid to grass, with various outbuildings that offer additional accommodation for service users to use for leisure and activities, including art and craft and a sensory room. All accommodation is in single bedrooms. The communal areas consist of two lounges, one dining room and a dining area. There is limited car parking in the front of the property. The fees range at the time of inspection is from £1442-£2642 per week. DS0000011297.V308557.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit from 10.15am until 6.00pm on 24th of October 2006. This report also includes reference to documents completed and supplied by the home, and those examined during the course of the site visit. The report also draws from very limited conversation with residents, who have limited verbal communication, the manager and two staff members on duty at the unit. No resident questionnaires were completed by, or in consultation with residents. The inspector also examined the majority of the premises, and ate lunch with residents, as well as making informal observations of interactions between staff and residents at various points during the inspection. Indications from observation of the interaction between residents and staff, were that the residents were relaxed and enjoyed interacting with the staff and the activities provided. The residents are encouraged to have some involvement in the day-to-day operation of the home in terms of household routines, and to make some choices and decisions for themselves with support and prompting by staff. The home had a relaxed and calm atmosphere. What the service does well: Effective care planning systems are in place and are to be further improved, and residents are encouraged to take part in the daily routines and make decisions and choices for themselves with support. Residents have opportunities to take part in a good range of activities both in the unit and outside, and are part of the local community. Contact with family is supported and next of kin are involved in decision making where appropriate. Residents are encouraged to take part in day-to-day routines and supported to do this. They are also involved in menu planning, shopping and food preparation, and receive a varied diet. Residents are supported effectively by staff with due regard for their likes, dislikes and personal preferences, and their healthcare needs are met effectively. The home has good links with external healthcare professionals. DS0000011297.V308557.R02.S.doc Version 5.2 Page 6 Medication is managed effectively on behalf of residents, and regularly reviewed; and good records are maintained. The home has appropriate systems in place to reduce the risk of harm to residents and has responded correctly when a concern arose. For the most part, the physical environment was homely and comfortable, and some issues had already been addressed, or were in hand. The service has a quality assurance system in place including questionnaires to residents, relatives, staff and care managers. A summary report is produced and the home also has the required annual development plan. (See below) What has improved since the last inspection? What they could do better: Residents’ care plans should be reviewed on a more frequent basis than annually as at present. It is recommended that a photo of the service user is added to their medication records. Consideration should be given to how best to convey the concept of the complaints procedure to residents. Some areas of the building required new flooring/redecoration though the manager reported most was included in her capital bids to be addressed. Three health and safety-related issues relating to the premises do need to be addressed. DS0000011297.V308557.R02.S.doc Version 5.2 Page 7 The provider needs to address any shortfalls in core training or required training updates, and needs to continue to focus on improving the proportion of staff with NVQ following recruitment of a number of new staff. The provider needs to consider how to improve the involvement of the residents and manager in future staff recruitment, as the recent overseas recruitment excluded both parties. The absence of fully completed recruitment records on site meant that it was not possible to verify that the process had been fully carried out according to the stated policy. This must be addressed. Although the home has a quality assurance system in place the views of service users were not sought as part of the last cycle. Consideration should be given to how best to obtain their views as part of the QA system. The required regulation 26 monitoring visits had taken place on a monthly basis, as required and the resulting reports were present. Improvements are needed to the accident records, the fire risk assessment and residents fire evacuation plans. 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. DS0000011297.V308557.R02.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 DS0000011297.V308557.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with information in written and symbol format, though it was explained that it would be very hard to provide the necessary information in a format that would be readily understood by current residents. Aspects of the information provided, would be explained verbally to a prospective resident and\also to their relatives/advocates etc. Although copies of initial assessments were unavailable due to archival, there was evidence from current care plan and other documents that the current needs/wishes etc. of residents were effectively identified and addressed. EVIDENCE: A detailed service user guide was in place, which had been translated via a computer programme into symbol form, but it was acknowledged that owing to the residents’ levels of understanding, it would be very difficult to devise a written or pictorial format that would be understood by residents. A more straight-forward form of the complaints procedure could be devised, which might, with explanation, be helpful to communicate the idea of who to talk to if a resident was unhappy. The advice of the speech and language therapist should be sought in this regard. (Recommendation made under Standard 22). DS0000011297.V308557.R02.S.doc Version 5.2 Page 10 The existing group are all long-term residents, and any initial assessments at the time of admission were not readily available, having been archived in the attic. Detailed care plans were, however, in place for each resident together with separate action plans and other documents to indicate how identified needs would be met. These documents indicated that the current needs of residents were being identified and addressed by the service. DS0000011297.V308557.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Effective care planning systems are in place. Residents are enabled to make day-to-day decisions and choices and there are plans for further developments in care planning and communication, which will enable further engagement with them. Residents care plans should be reviewed on a more frequent basis than annually. Residents are supported to take risks within an appropriate risk-assessment framework. EVIDENCE: All of the care plans had been reviewed and updated to a new format, which incorporates information regarding likes and dislikes, as well as information on how to engage with each individual and how each communicates. The manager and deputy have received training on an improved format for care planning which will be introduced later, once the new team is more DS0000011297.V308557.R02.S.doc Version 5.2 Page 12 established and the staff have completed their LDAF induction and received training in its use. There is also a separate action plan, detailing how issues identified in the care plan are to be addressed. Individual risk assessments are also in place for identified issues, and individual behaviour management guidelines are also provided, which are very detailed. Staff complete detailed daily report forms for each resident and keyworkers complete monthly reports. The manager had recently introduced an improved daily record format with space for staff to detail any therapeutic interventions or significant interactions with individuals. This should provide more useful structured information on the progress of individuals towards their care plan goals. The format also includes details of any personal care support given. Behavioural observation charts are also used to enable monitoring of the effectiveness of any behaviour management strategies in place. These are completed for any relevant incident or instance of a significant behaviour and are reviewed weekly by the psychologist. However, at present, care plans are only reviewed on an annual basis and this should take place every six months. Alternate reviews, in between the statutory annual reviews may be less formal but should involve relevant professionals and others as required. A number of boards were located about the unit with Makaton symbols on velcro, for use by staff and residents to facilitate more effective decisionmaking and the communication of their choices. The manager is consulting with a speech and language therapist on broadening this approach, to include other aspects of daily life including within the dining rooms, and the development of an activities board. Two of the residents indicate their choices by signing, some use pointing or leading the staff member to a desired activity or location. Two are able to communicate verbally in a limited fashion, to staff who are familiar with their vocalisations. At breakfast time the routine has recently been changed to try a buffet style, with the available options laid out, to enable residents to make direct choices themselves with any necessary support. This was reported to be proving successful. DS0000011297.V308557.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to take part in a good range of activities, both on and off-site and are part of the local community. Family contact is supported and next of kin are consulted and involved in decision-making where appropriate. The rights of residents are respected and they are encouraged to take part in day-to-day household tasks and make decisions about their lives. Menus are produced in consultation with residents and reflect their likes and dislikes. Mealtimes are pleasant and staff eat with residents, offering any necessary support and encouragement in a relaxed way. Residents are encouraged to take part in shopping and meal preparation. EVIDENCE: Within the staff team there is a day-care organiser who works full-time Monday to Friday and is assisted by a further day-care officer in planning and leading the delivery of the activities programme. From 10am, once most personal care DS0000011297.V308557.R02.S.doc Version 5.2 Page 14 support tasks are completed, the care staff also engage in activities with the residents. The day-care organiser meets with his counterparts in other units within the organisation ton share ideas. During the inspection, residents were seen engaged in a variety of activities including using the computer, relaxing in the lounge to a relaxation CD, (having had a foot spa), preparing tickets for the upcoming Halloween party, and assisting with/watching the preparation of pumpkins for the party, which was due to be held at a local hall. The staff were working hard to engage residents to take part in the activities as well as observing. It was evident that residents were enjoying their involvement in the various activities taking place. Although some activities take place in the house, there is also a heated summerhouse in the garden, which is used for art and craft activities. The manager is seeking funding for a further summerhouse to broaden the range of available options and enable small groups to work in different areas. Staff have converted one of the other garden buildings into a sensory room, with soft seating and various sensory equipment, though the room might benefit from the provision of some additional equipment. Risk assessments are undertaken where necessary relating to activities such as swimming and horse riding. The residents’ preferences are well known but they are offered opportunities to take part in new activities as well as sticking to their regular schedule. Residents also access activities in the community as well as being known at the local shops and nearby pub. Residents eat out at local restaurants, go out for walks locally, and drives out in the unit vehicles. They also go to organised outside activities including trampoline sessions, (with a trained instructor), where three are working towards achievement awards, bowling and cookery. Residents all choose to attend a weekly social club, (run by home staff), for residents in all of the organisation’s units. This provides wider social interaction, games and music. One resident used to attend a college Monday to Friday, and the manager is seeking to re-establish this for her, and another resident. The manager is in the process of seeking hydrotherapy sessions for residents. Residents spiritual needs are addressed where necessary. Preparations are being made for one resident to visit the mosque. He has been allocated a keyworker of the same faith to assist in this process. Appropriate discussions have taken place with family, regarding any other necessary considerations in the light of his cultural origin and religion. Appropriate music CD’s are provided DS0000011297.V308557.R02.S.doc Version 5.2 Page 15 for this resident to enjoy in his bedroom. Discussions with family have also included the provision of appropriate translation of the PRN medication guidelines, and of the minutes of review meetings. Plans for a possible future visit to family in Bangladesh are also under consideration, including a thorough risk assessment process. The cultural needs in terms of specialist hair care, for another resident are addressed by bringing in a specialist hairdresser to meet her needs. Each file has a record sheet for family contact to ensure that any necessary information is passed on. Family contact varies but is supportive, and encouraged. Four out of eight families responded to the homes last Quality assurance survey in January and their feedback about their perceptions of the home was positive. None were present on the day of inspection for the inspector to speak to. For the recent summer holiday two locations were offered to residents, including a different range of available activities etc. and half of the group went to each location. Staffing was provided one-to-one. The residents have some involvement in day-to-day household tasks including cleaning and hoovering their bedroom and are also encouraged to take part in general cleaning, table laying and clearing etc. and some shopping. Staff work to develop the independence of residents, where possible. A cook is employed to prepare the main meal of the day, which is at lunchtime, and care staff prepare the other meals. Almost all of the staff had current food hygiene training, which is provided as part of the core-training package, except for the most recent recruits. The cook was in the process of changing the menus over to a winter set, to reflect the change in climate. She consults with the residents individually to seek an idea of likes and dislikes. Rice dishes have been included for one resident and curries for another. There are usually two meal options prepared, though residents make their choice a week ahead to try to avoid too much wastage, which could lead to some difficulties. One resident’s family bring in additional curries for him. Vegetarian dishes are provided and the advice of a dietician has been sought regarding the needs of one resident. It was positive that staff ate meals with the residents as it makes for a more homely and natural environment. DS0000011297.V308557.R02.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported effectively by staff with due regard for their likes, dislikes and personal preferences. The home maintains detailed records of the support needs of individuals and how they should be met. The health needs of residents are also effectively addressed. The home has good links with external healthcare providers and health care records are well maintained. Residents’ medication is managed effectively on their behalf and is reviewed annually. Medication records are well maintained, though the inclusion of a photograph with each resident’s MAR sheet should be considered. EVIDENCE: Each resident is supported by individual behavioural guidelines, which are very detailed. Any physical interventions and other behavioural management techniques are recorded. The unit has a policy of only using “leading“ techniques, except in an emergency. Behaviour management plans are reviewed weekly, by the psychologist. As noted earlier there are Makaton symbols available in some areas to assist communication, and there are plans to broaden their use. An activities board is DS0000011297.V308557.R02.S.doc Version 5.2 Page 17 to be developed in consultation with the speech and language therapist, who is going to assess the communication skills of residents and provide relevant training to staff. There is also a sensory room available in one of the garden buildings. The manager plans to obtain a specialist bath, with OT advice, to meet the changing needs of one resident. During the inspection, staff were observed effectively supporting residents in day-to-day living skills as well as interacting proactively with them. It was evident from observation that residents enjoyed the contact with staff. Two residents are supported by specific staff who carry a tag to identify them, which is physically handed to another staff member when passing on the lead role with each individual, to ensure clarity and focus is maintained; since the physical whereabouts of both residents needs to be known at all times. Where benefits are identified, and it is possible within the available team, a culturally appropriate keyworker will be allocated. A resident was recently supported to swap bedrooms to a larger room, which better meets her needs, and this was carefully planned and undertaken at the resident’s pace. The staff have received training on meeting the needs of residents with impaired vision in the past and the manager felt it might be beneficial to refresh this. The resident for whom this is an issue has lived in the unit for an extended period and is able to find his way around effectively, though staff support him when out in the community, by warning him of upcoming level changes, kerbs etc. Each resident has an individual healthcare plan as part of their care plan, including weight records and there are individual records of contact with healthcare professionals. Residents’ medication is reviewed annually. The home has an appropriate medication management system, where one staff member administers medication and another acts as witness. Medication is also administered in the office to reduce the risk of distraction and consequent errors being made. Staff receive medication training and also an in-house medication assessment, including the completion of a questionnaire, before being authorised to administer medication. Each resident has a medication administration record (MAR) sheet, and an individual medication profile. There were also letters from the GP authorising DS0000011297.V308557.R02.S.doc Version 5.2 Page 18 any homely remedies. MAR sheets were in order and included a record of the quantities of medication coming into the home. The home’s medication management is reviewed periodically by the pharmacist. It would be good practice to include a photograph with the MAR sheet and other medication records, for each resident as a reminder, and consideration should be given to providing this. Five residents are prescribed emergency medication for epilepsy, and all of the staff receive training in its administration within their first aid course. DS0000011297.V308557.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. It was not possible to establish from residents whether they felt any concerns would be listened to, but the complaints log did indicates that concerns raised by others were addressed appropriately. Although a residents’ version of the complaints procedure had been produced using images and text, it remained too detailed and complex. The possibility of devising a simplified version, which might enable resident to express when they were unhappy about something, should be discussed with the speech and language therapist. The home has systems in place to protect residents from harm, and appropriate action is taken where any concerns arise. EVIDENCE: The home has a complaints system in place. The complaints log indicates that issues raised had been appropriately addressed. The complaints procedure had been provided in a form with text and symbols, but it remained rather complex, and it appeared unlikely to be readily understandable by the residents. A rather simpler form of the complaints procedure could be devised, which might, with explanation, be helpful to communicate the idea of who to talk to if a resident was unhappy. DS0000011297.V308557.R02.S.doc Version 5.2 Page 20 The advice of the speech and language therapist should be sought. It was explained that all of the residents were able to indicate they were unhappy or upset, but would have little understanding of the concept of a complaint. Staff are able to act as advocates on behalf of a resident where appropriate. Appropriate POVA guidance was present for staff in a dedicated file, which also included the contact numbers for management, residents’ care managers and parents, as well as the regulation 37 reporting format. Appropriate steps were taken when a POVA concern arose recently, which is still under investigation. Staff receive POVA training as part of their core training. DS0000011297.V308557.R02.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment provided for residents is homely and comfortable for the most part, though lounge furnishings urgently need new covers or replacement, and some other issues require attention. Three potential health and safety issues were identified and need to be addressed. The home was found to be clean and hygienic. EVIDENCE: The unit comprises a detached house and adjacent bungalow, joined together by an extension, providing two lounges, a dining room and separate dining area, and single bedroom accommodation for residents. There is a large garden, mainly laid to grass, with outbuildings that offer additional accommodation for service users to use for leisure and activities, including art and craft and a sensory room. DS0000011297.V308557.R02.S.doc Version 5.2 Page 22 Limited car parking is provided in front of the property. The manager reported that new bedroom furniture was to be purchased for five of the bedrooms, together with some new bedroom flooring. In one bedroom the laminate flooring had become loose, and potentially removable in some areas, where the resident had been tampering with it. Consideration needs to be given to the most effective flooring for this bedroom to ensure the resident’s health and safety. Two of the bedrooms, the hallways and stairs and one lounge had already been re-carpeted. The bedrooms were personalised and reflected the needs and interests of their occupant. The photomontages were a positive addition. Funding for an adapted bath, to meet the changing needs of one resident has also been included in budgetary plans. The décor within communal areas was mostly satisfactory, with some areas of minor damage which the manager reported would be addressed within the regular maintenance cycle. The covers on the lounge furniture were worn and torn in places. The manager stated that these were included in her submitted expenditure budget for replacement, and these should be replaced as a priority. The cooker was also scheduled for replacement with a more domestic style appliance. As already noted the manager has plans for a second summerhouse to broaden the range of facilities for art and craft activities, and had submitted a bid for funding for it. She was also seeking to have the patio area re-laid as it was fragmented and uneven, presenting a potential health and safety hazard. The manager plans to set up additional Makaton symbol boards in bathrooms and dining areas to aid communication, in liaison with the speech and language therapist. It was also stated that the staircase was rather steep and may need to be adapted to improve safety. There had reportedly been four accidents to staff and residents on the stairs in the past four years. It would be prudent to have the stairs assessed by an OT and to act on their recommendations, to ensure that any health and safety considerations are addressed. The home’s laundry facilities meet the needs of residents. The washing machine is equipped with a sluice cycle. Standards of hygiene and cleanliness in the home were satisfactory. DS0000011297.V308557.R02.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by a competent team who receive an appropriate induction and foundation training, though there were some shortfalls in required core training updates owing to the level of staff turnover, which should be addressed by the provider. Staffing levels appeared appropriate to meet the needs of residents, with two being supported on a one-to-one basis throughout the day. The level of staff having attained NVQ was very low, owing to staff turnover, though a significant number were either undertaking their NVQ or registered to do so. The reported recruitment system provides protection for service users, but the absence of fully complete records in the unit did not enable the process to be verified readily. The recent overseas recruitment campaign excluded the home’s manager and residents from any involvement in the process, which is not best practice, and this should be addressed within future recruitment plans. DS0000011297.V308557.R02.S.doc Version 5.2 Page 24 EVIDENCE: Staff were observed to be respectful in their dealings with residents and demonstrated an understanding of their individual means of communication, and support was provided with due regard to their dignity. One staff member is also the training coordinator, and also maintains an overview of NVQ for the team. All staff undertake an initial unit induction, for which a new record has been devised, which includes dates and signatures, which is good practice. They also commence their LDAF foundation training alongside this. This includes POVA, first aid, moving and handling, health and safety, fire safety, food hygiene, epilepsy, autism, anti-disciplinary practice and SCIP (Strategies for Crisis Intervention and Prevention). Elements of the completed LDAF record can be offset against NVQ units, when staff progress onto NVQ after completion of the LDAF foundation training. The training is sourced from a local college and other external trainers. Given the turnover of staff there has been a need to prioritise training to new staff over providing updates for the existing team at times, but the management are working to address this. However, examination of the training record seemed to indicate that some staff had not received fire safety training updates since 2002/3. The manager needs to check this and address any shortfalls. Other gaps in core training were evident. The provider should consider the provision of additional training dates in the short-term, to bring any statutory training updates into line. At the time of inspection, seven staff had completed induction and were undertaking LDAF foundation training, with a further four registered and awaiting the arrival of their LDAF record books. Seven had commenced NVQ level 2, and two were in the process of level 3. No staff had already attained level 2. The manager had NVQ level 3 and was in the process of her level 4 and RMA (Registered Manager’s Award). Staff are supported through an effective supervision hierarchy and there was a written record of sessions enabling monitoring. The manager also operates an open door policy so staff can discuss any concerns at the time they arise. Preparations have been made for a cycle of appraisals, though only one had been completed at the time of inspection. The manager intended to schedule these in for the other staff. DS0000011297.V308557.R02.S.doc Version 5.2 Page 25 The unit currently has two deputies in post though one is leaving. The manager is proposing to combine some of the hours from this post and another to create another shift leader post to bolster the middle management structure and enable most shifts to be covered by either a shift leader or senior support worker. The unit’s usual staffing is five staff including a senior on the early shift, four staff including a senior on late shifts, plus two dedicated day-care staff until 5pm, and two waking night staff overnight. The home had only one vacant care staff post at the time of inspection, resulting in low levels of agency use. The provider had recently undertaken a successful recruitment campaign in Poland, resulting in the recruitment of eight new staff. There were two drawbacks to this style of recruitment, the lack of involvement of the unit manager in the process and the lack of opportunity for residents to have any involvement. These factors should be considered when any similar overseas recruitment drives are planned. Consideration should, in any case, be given to possible ways to engage residents in the recruitment process for new staff. Examination of a sample of recruitment records indicated that the organisation has opted to retain only a checklist of recruitment records on-site, with original documents held at head office, rather than retain copies of required evidence of the vetting process. This option is only acceptable if the checklist on-site is fully complete, dated and signed. This was found not to be the case for one of the sampled records, where information regarding evidence of ID confirmation and CRB/POVA was incomplete. The provider must ensure that records held within the unit provide evidence of all aspects of the required vetting process. A separate list of CRB numbers, did not confirm the level of the CRB, or whether the applicant had any convictions/POVA entries. However, the manager retains a record of interviews, which is good practice. DS0000011297.V308557.R02.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run effectively and with the best interests of residents in mind. Although the views of residents are taken in residents meetings and informally day-to-day, residents had not been supported to enable completion of either the CSCI resident questionnaire, or the home’s quality assurance questionnaires. The service needs to develop its skills in this area. The required summary report of the quality assurance survey and an annual development plan for the service, were in place. The required monthly regulation 26 monitoring visits have been carried out, and the reports were filed in the unit. Improvements are needed to accident records, the fire risk assessment and resident evacuation plans. DS0000011297.V308557.R02.S.doc Version 5.2 Page 27 EVIDENCE: The manager is appropriately experienced to manage the service and was undertaking her NVQ level 4 and RMA at the time of inspection. The home has a clear hierarchy of responsibilities and clear systems in place. Five residents meetings had been held this year though these were not regularly spaced, with one being specifically focused on planning the summer holiday. The staff advocate for the views of residents within the meetings, where they are unable to communicate their views readily. Accident records are made on a small tear-off format, smaller than the standard A4 pad, which makes it difficult to copy the form for filing in the required locations. The forms are monitored and countersigned by the manager, and entries were sufficiently detailed, with an attached incident form where appropriate. At present the forms are held collectively in a zip wallet as a collective record but may not be in date order, as they are not secured. It is suggested they are secured in a file in date order. Copies of accident forms are not currently filed within the case record of the relevant resident as required, and a system must be devised to address this. (The simplest method is just to file a photocopy within a dedicated section of the relevant individual case record). An appropriate risk assessment system is in place and the completed risk assessments seen on file were detailed. Examination of a sample of health and safety-related service certification indicated most to be up to date, though the annual gas safety check for the cooker was overdue and should be arranged promptly. As noted earlier, the latest fire safety training for some staff was listed as happening in 2002/3. Any staff who have not had a recent fire safety training update must receive this as a priority. (Requirement made under standard 35). Fire drills have been held periodically. However, the fire risk assessment needs to be reviewed and individual evacuation plans for residents need to be drafted. A quality assurance review was undertaken in January 2006, with questionnaires provided to residents, relatives, care managers and staff in December 2005. However no questionnaires were returned by residents, and no one assisted them to complete the forms in an advocacy role. DS0000011297.V308557.R02.S.doc Version 5.2 Page 28 Consideration should be given to how best the views of residents could be obtained to inform the next quality assurance cycle. A summary report was produced of the findings, which were very positive for the most part. The manager produces an annual business plan, which addresses the range of issues relevant for an annual development plan for the service. Regulation 26 monitoring visits had taken place as required. The reports were available in the unit and were appropriately detailed. It was reported that a new individual was being recruited to undertake these visits. DS0000011297.V308557.R02.S.doc Version 5.2 Page 29 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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 x DS0000011297.V308557.R02.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15(2)(b) Requirement The manager must ensure that resident’s care plans are reviewed at least on a sixmonthly basis. The manager must ensure that the identified health and safety issues are addressed. The manager/provider must ensure that comprehensive evidence is available on-site, of the required recruitment checks having been undertaken. Part of this requirement is carried over from a previous requirement for evidence of POVA checks to be available. The manager/provider must ensure that any shortfalls in core training/periodic updates, must be addressed promptly. The manager must ensure that records of resident accidents are filed on their individual care files in addition to being filed collectively for monitoring. The manager must update the home’s fire risk assessment to include individual fire evacuation plans for residents. Timescale for action 24/12/06 2 3 YA24 YA34 13(4) 19 and Sched. 2 24/12/06 24/12/06 4 YA35 18 24/12/06 5 YA42 17(1)(a) & Sched. 3.3(j) 23(4)(c) 24/12/06 6 YA42 24/12/06 DS0000011297.V308557.R02.S.doc Version 5.2 Page 31 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA20 YA22 YA34 YA39 Good Practice Recommendations Consideration should be given to the inclusion of a photo of each resident with their medication records. Consideration should be given to further simplification of the complaints procedure, in consultation with the speech and language therapist. Due consideration should be given to the involvement of the home’s manager and residents in the recruitment process for staff. Consideration should be given to how to support residents to enable them to contribute their views in response to quality assurance questionnaires. DS0000011297.V308557.R02.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000011297.V308557.R02.S.doc Version 5.2 Page 33 - 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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