Inspection on 21/08/07 for Hoffmann Foundation for Autism 11 Pear Close

This inspection was carried out on 21st August 2007.

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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hoffmann Foundation for Autism... 05/02/07

Hoffmann Foundation for Autism... 10/10/05

Hoffmann Foundation for Autism... 20/10/04

Hoffmann Foundation for Autism... 20/05/04

Hoffmann Foundation for Autism... 28/01/04

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Ashlong House

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Edenvale

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Hoffmann Foundation for Autism 11 Pear Close Hoffman De Visme Foundation 11 Pear Close Kingsbury London NW9 0LJ Lead Inspector Julie Schofield Key Unannounced Inspection 21st August 2007 09:05 Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.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 Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.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. Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hoffmann Foundation for Autism 11 Pear Close Address Hoffman De Visme Foundation 11 Pear Close Kingsbury London NW9 0LJ 020 8200 8667 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) Hoffmann Foundation for Autism Manager post vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th February 2007 Brief Description of the Service: The home is one of a number of care homes operated by the Hoffmann Foundation for Autism. It provides accommodation and personal care for 6 adults with learning disabilities. At the time of the inspection there were no vacancies. The home is located within a residential area of Kingsbury, within the London Borough of Brent. It is close to local shops and bus routes and there is parking outside the home and in the nearby streets. There are two bedrooms on the second floor and a shower room with a toilet. Four bedrooms, 2 offices and a bathroom, with toilet, are situated on the first floor. On the ground floor there is a lounge, a large kitchen/dining room, a laundry room, a toilet and an activity day care room/staff sleeping in room. Leading from the day care room is a bathroom, with a toilet, and a small kitchen. Access to the garden is through patio doors leading from the lounge and from the dining area. At the time of the inspection the manager’s post was vacant. Information regarding the fees charged may be obtained, on request, from the manager of the home. Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a Tuesday in August. It began at 9.05 am and finished at 5.05 pm although a break was taken in the afternoon. During the inspection discussions with the deputy manager and members of staff took place. Most residents are unable to give verbal feedback so time was spent with residents, observing the care practices of members of staff on duty and the rapport between residents and staff. Records, policies and procedures were examined. Case tracking was undertaken. Compliance with the statutory requirements identified during the previous inspection was checked. A site visit was carried out. The preparation of the evening meal was observed. The Inspector would like to thank everyone for their part in the inspection. What the service does well: What has improved since the last inspection? During the previous inspection in February 2007 six statutory requirements were identified and of these 2 have now been met. Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 6 That service users wear a dressing gown over their nightclothes when seated in communal areas. That the sealant is replaced around the wash hand basin in the second floor bedroom. The statutory requirement relating to the manager that was in post at the time of the previous inspection has been withdrawn, as the person is no longer in post. What they could do better: During the inspection 9 statutory requirements were identified and 3 of these were outstanding from the previous inspection: Care plans must be reviewed on a regular basis. All sections of the personal planning books must be completed so that goals are identified and the action needed to achieve the goals specified. Residents must not be expected to pay for fixtures or fittings that are the responsibility of the company to provide. A refund needs to be made to the resident concerned. The replacement, repair and redecoration identified during the site visit must be carried out as parts of the building do not meet the standards expected for a home accommodating residents. All members of staff must receive training in infection control procedures and in order to maintain good standards of hygiene soap, toilet paper and paper towels must be provided in the bathrooms for the benefit of the residents, staff and visitors. Recruitment process must ensure that all checks are carried out and the validity of references needs to be confirmed when “to whom it may concern” references are supplied. An application for registration must be made by the successful candidate for the manager’s post, as there has been no registered manager for the home since October 2006. Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 7 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. Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.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 Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.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 People who use this service experience good outcomes in this area. Receiving information about the home prior to admission enables prospective residents (and their relatives) to make an informed choice. A comprehensive assessment of need prior to the admission of the resident assures the resident that the home is able to their individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and the Service User Guide were available for inspection. Although they included most of the recommended information the Service User’s Guide lacked information in relation to the fees charged. Information regarding the registered manager was out of date as the name of the person entered is no longer working in the home and it is recommended that both documents are reviewed and amended, as necessary. The home has an admission procedure, although no new resident has been admitted to the home since the last inspection. The policy is that if a referral is made a representative of the company will carry out a comprehensive assessment of the needs of the prospective resident. This information would be in addition to the information provided by the funding authority, which Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 10 would include a copy of their needs assessment for the prospective resident. In addition to the combined information, a programme of pre-admission visits to the home, by the resident, would be carried out so that the home is able to determine whether a service can be provided that would meet the individual needs of the resident. Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.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, 9 People who use this service experience adequate outcomes in this area. Although care plans are in place one was incomplete and the home was unable to demonstrate that changes in the needs of residents are identified and addressed, as review meetings are outstanding. Residents are supported to manage their finances and there is a need to make sure that the management of individual’s personal money includes consultation with persons acting on behalf of the resident. Responsible risk taking contributes towards the resident leading an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The case files of 3 residents were examined. It was noted that on one file, in 2007 a placement review meeting was convened by the funding authority (where relatives were invited to attend to support the resident) and that the Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 12 home had convened a person centred planning meeting. The person centred planning meeting reviewed the goals set in the personal planning book. The second file contained evidence of an annual review in 2007 by the funding authority but not evidence of a review meeting convened by the home. The deputy manager said that the review meeting convened by the home was overdue on the third case file due to the resignation of the manger of the home. The personal planning book, kept on file, included “My Action Plan” but on one file some sections had been left blank e.g. goals and action plan. Files also contained guidelines for staff in supporting residents with a range of activities e.g. personal care, cooking, swimming, bathing etc. Copies of these are in a file that is kept on the ground floor and is available to staff, for reference. A member of staff said that she found them helpful. It is recommended that these be also subject to regular reviews. Monthly evaluations were carried out and kept on file. They were up to date on 2 of the 3 files. The deputy manager said that each resident is helped by the home to manager their finances and that the home will provide help if the resident has problems with their benefits. The financial records were available and it was noted that residents had bank accounts in their own names. A record was kept of when money was withdrawn from the bank and deposited in the home, when money was spent, what money was spent on and the balance that remained. Receipts were kept to confirm items of expenditure. Accounts were up to date and complete, although it is recommended that for large items of expenditure i.e. annual holidays, the home consult with a representative of the funding authority so that an independent person has agreed the costings. It was noted that a resident had paid for laminated flooring to be laid in their room. The deputy manager said that the resident had continence problems and the carpet in the resident’s bedroom had been removed. However the company would be expected to pay the cost of new floor covering and not the resident. Consultation and agreement regarding the new flooring had not taken place with an independent person, acting on behalf of the resident. Risk assessments were on file and were tailored to the individual needs of residents. They were due for review and it is recommended that they be reviewed on a six monthly basis. Risk assessments were in respect of travelling either by taxi or in the home’s minibus, going for a walk, shopping in the supermarket etc. Risk assessments included an identification of the risk setting, the risk factors, frequency of occurrence and measures to minimise the risk (risk management strategies). Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.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, 17 People who use this service experience good outcomes in this area. Using community resources gives residents the opportunity to enjoy an interesting and stimulating lifestyle. With staff support, residents are encouraged to maintain contact with their families and to enjoy fulfilling relationships. Residents are encouraged to make decisions and their wishes are respected and the home is to be commended for its use of “communication passports”. Residents are offered a varied and wholesome diet, which meets their cultural needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each of the residents has their own individual day care programme. To assist residents with recognising/remembering what activities they are taking part in on that day a picture/symbol/sign is displayed on a white board in the kitchen/dining area against their photograph. Three residents attend day Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 14 centres for either 3 or 4 days per week while the other three residents day care programme is based around Pear Close, although activities may take place inside the home e.g. painting, puzzles or reading sessions or in the community e.g. lunch out, going shopping etc. There is a separate activities/day care room on the ground floor of the house and this is sufficient in size for 3 residents to use this at the same time. On the day of the inspection three residents went to their day centre and the remaining residents went to the local leisure centre to play football or for a keep fit session. The home has its own transport, a 7 seater minibus. Residents make use of community resources and facilities including parks, pubs, the cinema, theatres and leisure centres. On the day of the inspection a resident wanted to go to the pub for a drink and another resident wanted to go for a walk. Staffing levels were sufficient to accommodate this. It was noted that although residents’ names had been entered on the electoral roll a letter had been returned by the home stating that they were not entitled to vote as the premises are used as business premises. It is recommended that the home correct this mistake. Residents benefit from an annual holiday and in 2006, 2 residents went abroad and 4 residents went to Colchester. So far 3 residents have been on holiday this year. Two residents went to Portugal and 1 resident went to the seaside in the UK. The home is currently arranging holidays for the remaining 3 residents. During the evenings and weekends residents are able to attend clubs, if they wish. Within the home residents may wish to relax or in the evenings there are activities that take place in the day care room. Staff encourage and support residents to maintain relationships with their families. Two residents receive visits from their family and their family takes them out or staff may take the resident to meet their family and then collect the resident later in the day. Some families maintain contact by telephone calls. If the family visit the home the resident can sit with their visitors in the resident’s bedroom or in the lounge. Discussions took place regarding the residents right of choice. The speech and language therapist had recommended that the home introduce a “communication passport” for one of the residents and this has been done. The book was available and contained pictures relevant to that resident and to their individual lifestyle. The home has also started to introduce these for other residents so that staff can offer more choice to residents and understand the wishes of the resident, even if the resident is unable to make these known verbally. There are plans to introduce a key ring selection of pictures that can be used when residents are in the community and choice is being offered. The home is to be commended for this development. Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 15 The menu for week commencing the 20th August was examined. It was varied and included African-Caribbean foods to meet the cultural needs of AfricanCaribbean residents. There was evidence that alternatives were offered if a resident did not like any of the food prepared and when this happened it was recorded. The menu was part of a 4-week menu cycle. On the day of the inspection the preparation of the evening meal was observed. The meal consisted of chicken, boiled potatoes and vegetables. It looked and smelt appetising. Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People who use this service experience good outcomes in this area. Discreet and caring support is given to residents by staff so that the privacy and dignity of the resident is respected. The health and well being of residents is promoted through regular health care checks and appointments. Residents’ general health and well being is promoted by staff that assist residents to take prescribed medication in accordance with the instructions of the resident’s GP. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A statutory requirement was identified during the previous inspection in February 2007 that service users wear a dressing gown over their nightclothes when seated in communal areas. The inspection started when some residents were coming down stairs for breakfast and it was noted that all residents were appropriately dressed. This requirement is now met. It was noted that assistance with personal care was offered in a manner, which respected the dignity of the resident. Female carers assist female residents. The home uses Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 17 a key worker system and a member of staff on duty was able to explain the duties that this entailed. Residents’ case files included details of health care needs. It was noted that residents had access to health care facilities in the community. Regular and recent appointments were noted with the optician and the dentist. Residents had appointments with GP, when necessary and medication reviews have taken place. Residents had access to routine screening e.g. blood tests. Staff supported residents to attend out patient appointments at the hospital. If necessary specialist intervention is sought and a referral had been made to the speech and language therapist on each of the 3 case files examined. Medication records were inspected and the recording of the administration of medication to residents was up to date and complete. However a list of staff responsible for administration is needed and this must include a specimen record of their initials and the date on which their competence at carrying the task was assessed and deemed satisfactory. The storage of medication was safe and secure. Medication had been satisfactorily administered to residents prior to the inspection in accordance with the day of the week and the time of day that the medication was checked. Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People who use this service experience good outcomes in this area. A complaints procedure is in place to protect the rights of the residents. An adult protection policy and protection of vulnerable adults training for staff contributes towards the safety of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure in place, which has timescales for each stage of the process. If a complaint cannot be resolved locally a senior manager within the company deals with the complaint. The policy advises the complainant of their right to contact other agencies that are involved in the process e.g. the Commission for Social Care Inspection (CSCI), the local authority and the Ombudsman. The deputy manager said that no complaints made on behalf of residents have been recorded since the last inspection, although a number of complaints have been received from a neighbour regarding noise levels. Records were complete and included details of the investigation carried out. The CSCI has also received a complaint regarding noise levels, which has been investigated by the Operations Manager. The complainant has been notified of the outcome. The residents are unable to make complaints verbally and the manager confirmed that referrals for advocacy services have been made on behalf of those residents without family Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 19 support. There is a user friendly complaints procedure that has been developed where pictures and symbols are used to convey the meaning. The home has an adult protection procedure in place and has a copy of the local authority’s interagency guidelines. Induction training held at head office includes protection of vulnerable adults training. The deputy manager said that no incidents or allegations have been recorded since the last inspection. Staff on duty confirmed that they had received training in protection of vulnerable adults procedures. Staff files contained evidence of a satisfactory enhanced CRB disclosure being obtained. Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 People who use this service experience poor outcomes in this area. The standard of décor throughout a number of areas in the home does not meet the standard expected for providing residents with pleasant and smart surroundings. Hygiene standards in the home are compromised by the lack of soap and paper supplies in the bathrooms and by the lack of infection control procedures training for all members of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A site visit was carried out and it was noted that the décor of the accommodation was poor. The bathroom on the second floor, paintwork and doorframes on the first floor and some of the first floor bedrooms needed redecorating. Rawl plugs had been removed and had not been filled and made good. A gouge in the plasterwork where a door handle had rubbed against needed attention. A number of wash hand basins, in bathrooms and in Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 21 bedrooms lacked a plug. The net curtains in the second floor bedrooms were torn at the bottoms and needed replacing. The curtain pole for the lounge window, at the front of the house was missing. There were chips of paintwork missing and a mark on the wall in the lounge. It was noted that in one of the bedrooms a television had been placed on a wall bracket behind the bed head. Due to the small size of the room and its layout the position of the bed could not be moved and the assistant manager said that the resident watched the television looking backwards over his head. Two statutory requirements were identified during the previous inspection in February 2007. The first requirement was that the bedrooms on the first floor are redecorated. This remains outstanding. The second requirement was that the sealant is replaced around the wash hand basin in the second floor bedroom. There was compliance. It was noted during the site inspection that all areas of the home were tidy and free from offensive odours. However in both of the bathrooms there was no soap, toilet paper or paper hand towels. The laundry room is situated on the ground floor and although small in size contains a commercial washing machine and a commercial drier. Using this room does not involve carrying soiled linen through any area where food is stored, prepared or eaten. A statutory requirement was identified during the previous inspection in February 2007 that all members of staff receive training in infection control procedures. One of the members of staff on duty said that they had not undertaken infection control training so this requirement remains outstanding. Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 People who use this service experience good outcomes in this area. Residents benefit from a service provided by carers that have demonstrated their skills and understanding through NVQ training. Residents are assured of sufficient staff on duty to meet their needs. Recruitment practices do not include all of the checks to ensure that the safety and welfare of residents is protected. The programme of training for staff encourages good working practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The progress of the staff team in relation to NVQ training was discussed. Of the 14 members of staff listed on the rota, 7 members of staff have achieved an NVQ level 2 and 2 members of staff have achieved an NVQ level 3. Another member of staff has a nursing qualification. Therefore the home has met the target of a minimum of 50 of staff that are qualified to an NVQ level 2 or 3 standard. In discussions with staff they demonstrated a commitment to their work and it was observed that they were motivated and were able to Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 23 communicate well with residents. They were knowledgeable when speaking about the needs of each individual resident. A copy of the rota was on display in the office. It was noted that there was a minimum of 3 support workers on duty on the early shift and on the late shift. The staffing levels depended on what activities the residents were taking part in and there could be 4 or 5 members of staff on duty at certain times. At night there is 1 member of staff on waking night duties and 1 member of staff that sleeps in but is on call. Staffing levels are maintained at the weekends. In addition, domestic staff work in the home. The company prefers to use bank staff in the home rather than agency staff and the staff team reflects the cultural/gender composition of service users. Staff meetings are held monthly and minutes are kept. Some residents communicate by signs and staff are able to respond to these. A statutory requirement was identified during the previous inspection in February 2007 that each staff file contains an enhanced CRB disclosure that has been obtained by the company and 2 satisfactory references. Five staff files were inspected. Each staff file contained evidence of a satisfactory CRB clearance so this part of the requirement is now met. Although each file contained 2 references, on one file these were addressed “to whom it may concern” and had been supplied by the applicant. There was no evidence on file that the validity of these references had been checked. Therefore the latter part of the requirement remains outstanding. There was proof of identity on each file. The company uses a probationary review form to record the progress of the member of staff during their probationary period. A copy of the company’s staff training calendar for 2007 was on display in the office. The company has a training office and training section based at Head Office. Information regarding training available to staff is sent to the home and the manager nominates staff to attend the courses. Each member of staff has an individual training record and there is an overall record for the staff team. Training may be either in-house, which takes place either in the home or at Head Office or it may be external. Supervision and staff appraisals identify staff training needs. Although no member of staff is currently undertaking induction training a copy of the booklet was seen and it referred to the Sector Skills Council’s and LDAF units. If staff need to develop their IT skills they use Learning Direct courses. Mandatory training for staff includes safe working practice topics, training in respect of the client group and protection of vulnerable adults. Staff also have access to training in relation to key working, challenging behaviour and equalities and diversity. Members of staff agreed that the training offered was supportive and helped them to carry out their duties. One member of staff on duty said that they had received training in respect of autism. A member of staff said that they received more than 5 days training in total in a year. Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.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, 42 People who use this service experience good outcomes in this area. Residents benefit from a manager that is able to develop and maintain good standards of care in the home and so recruitment to this post is vital. Information gained through the quality assurance systems is used to shape the future development of the service and ensure that the changing needs of residents are met. Training for staff in safe working practice topics promotes the health and safety of residents, staff and visitors to the home. Testing and servicing of equipment and systems in the home demonstrate that they continue to be safe to use. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 25 A statutory requirement was identified during the previous inspection in February 2007 that the manager completes and forwards an application for registration to the CSCI. The person that this requirement related to has since resigned their post so the registered manages post remains vacant. The deputy manager, who assisted during the inspection, is covering the duties of the manager until recruitment has taken place. The Service Manager, who was the registered manager of the home until October 2006, is supporting him. The company has a number of ways in which feedback on the quality of the service is obtained. Feedback from relatives may be given during their visits to the home. The company organises a forum (which is held on a quarterly basis) for relatives and residents to attend. Comments can also be given during the review meetings, to which relatives are invited, according to the wishes of the resident. In addition, on a quarterly basis a sample of relatives are sent a quality assurance feedback form. In respect of the placing authority a sample are sent a quality assurance feedback form and comments can be given during review meetings. The company also hosts a staff forum to gain feedback. The information received at Head Office is analysed and used to judge the standard of care in its homes and feedback is given to the homes. Newsletters are prepared by the company and are distributed to residents, staff, relatives of service users etc. A copy of the business plan for November 2006-9 was available. The company forwards a copy of the monthly Regulation 26 reports to the Commission for Social Care Inspection. There was evidence that staff receive training in safe working practice topics. The recent visit by the Food Safety Team confirmed that satisfactory standards were observed in the home. There was a fire risk assessment and valid certificates for the servicing/checking of the emergency lighting and call points, the fire extinguishers, the electrical installation, and the portable electrical appliances. An appointment for the Landlord’s Gas Safety Record inspection had been made. The accident book was seen and records had been satisfactorily completed. There was evidence that fire drills and the testing of the fire alarms are carried out on a regular basis. During the handover meeting that took place during the afternoon the names of the qualified first aiders on the shift were identified. Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.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 X 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 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 27 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15(2) Requirement Timescale for action 01/11/07 2 YA6 15(1) 3 YA7 16(2) 4 YA24 16(2) & 23(2) The registered person must ensure that care plans are reviewed on a regular basis so that residents are assured that changes in their needs are identified and addressed. The registered person must 01/11/07 ensure that all sections of the personal planning books are completed so that residents are assured that goals are identified and that the action needed to achieve the goals is specified. The registered person must 01/11/07 ensure that residents are not expected to pay for fixtures or fittings that are the responsibility of the company to provide and that a refund is made to the resident so that the resident’s financial interests are protected. The registered person must 01/01/08 ensure that curtains and curtain pole are replaced, that walls & ceilings & door frames are repainted, that plaster work is made good, that the second floor bathroom is redecorated and that plugs are fitted to wash hand basins so that residents DS0000017476.V348770.R01.S.doc Version 5.2 Hoffmann Foundation for Autism 11 Pear Close Page 28 5 YA24 23(2) 6 YA30 13(3) 7 YA30 16(2) 8 YA34 19(1) 9 YA37 8(1) enjoy comfortable and pleasing private space and communal areas. The registered person must ensure that the bedrooms on the first floor are redecorated so that residents enjoy comfortable and pleasing private space. (Previous timescale of the 1st July 2007 not met). The registered person must ensure that all members of staff receive training in infection control procedures to maintain a safe environment for residents, staff and visitors. (Previous timescale of the 1st July 2007 not met). The registered person must ensure that good standards of hygiene are maintained at all times by providing soap, toilet paper and paper towels in bathrooms so that the health of residents, staff and visitors is protected. The registered person must ensure that the validity of references is demonstrated to assure residents that unsuitable persons are not employed. (Previous timescale of the 1st May 2007 not met). The registered person must ensure that the Commission for Social Care Inspection (CSCI) receives an application for registration from the successful candidate for the manager’s post so that the CSCI can be assured that a suitable person has been appointed. 01/01/08 01/12/07 01/10/07 01/11/07 01/01/08 Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA1 Good Practice Recommendations That the Statement of Purpose and Service User’s Guide are reviewed and amended so that all the recommended information is contained in the documents and that the details are up to date. That the guidelines for staff, while supporting residents, are reviewed on a regular basis. That the monthly evaluations of the care plan are kept up to date. That when an annual holiday or a large item of expenditure is planned the costings are agreed with a representative of the funding authority, acting on behalf of the resident. That risk assessments are reviewed on a six monthly basis. That the home ensures that residents names are entered on the electoral roll and are recorded as eligible to vote. 2 3 4 YA6 YA6 YA7 5 6 YA9 YA13 Hoffmann Foundation for Autism 11 Pear Close DS0000017476.V348770.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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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