Inspection on 24/04/08 for Hunters Moon

This inspection was carried out on 24th April 2008.

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

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

Other inspections for this house

Hunters Moon 21/04/09

Hunters Moon 05/12/06

Hunters Moon 03/05/06

Hunters Moon 21/10/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Hunters Moon Grittleton Road Yatton Keynell Nr Chippenham Wiltshire SN14 7BH Lead Inspector Pauline Lintern Key Unannounced Inspection 24th April 2008 9:30 Hunters Moon DS0000064634.V362251.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 Hunters Moon DS0000064634.V362251.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. Hunters Moon DS0000064634.V362251.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hunters Moon Address Grittleton Road Yatton Keynell Nr Chippenham Wiltshire SN14 7BH 01452 300025 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) www.holmleigh-care.co.uk Holmleigh Care Homes Ltd Vacant Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Hunters Moon DS0000064634.V362251.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability (Code LD) The maximum number of service users who can be accommodated is 7. Date of last inspection 5th December 2006 Brief Description of the Service: Hunters Moon is one of a number of care homes owned by Holmleigh Care Homes Ltd, which operates homes in Gloucestershire and Wiltshire. It accommodates seven people. The home is located in the village of Yatton Keynell, close to Chippenham. There is a pub and a shop in the village. Hunters Moon was previously a family home, which has been adapted to include en-suite bathrooms with each bedroom. There are bedrooms on the ground and first floor. Access to the first floor is by stairs only. There is a large lounge, a conservatory, a dining room and separate kitchen and a separate utility area. A new extension has recently been build, which provides an additional communal area. There are large gardens to the rear of the home. Typically there are at least four staff on duty each day. There is one staff member sleeping in and one waking staff member at night. The home has a vehicle to take people out and about. Fees range from £1000 to £1800 per week depending on the person’s assessed care needs. Hunters Moon DS0000064634.V362251.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection took place over eight hours. The home is currently without a permanent registered manager. A manager has been seconded from another Holmleigh care home to manage the service until a new permanent manager has been appointed. A new deputy has been in post for three months. Both the manager and the deputy were present during the morning of our site visit. The manager explained that it was officially her ‘first day’ in post at Hunters Moon. She said that although she had a wide knowledge of the people using the service and the staff team she may not be fully aware of where documents and records are currently stored. The manager explained that the deputy and herself were in the process of reviewing all care plans and risk assessments. They were aware that due to a period of time without a manager in situ, many files were in need of updating. During our visit we were able to meet with all of the people using the service. However, due to people’s lack of verbal communication we were unable to obtain their views about the service being provided. We were able to observe interactions / body language and facial expressions of the people being supported with members of the staff team. We had the opportunity to meet with two members of staff in private to discuss their experiences of working at Hunters Moon. We spent time looking at two case files including risk assessments. We looked at the arrangements for medication and health and safety documents. A recent safeguarding issue had resulted in some documentation having been removed from the home by the investigating police officers. Prior to the inspection we requested that the home complete their Annual Quality Assurance Audit (AQAA). This was returned to us in February 2008 and provided us with the information we needed. Feedback from the inspection was given the following day by telephone, in agreement with the acting manager. What the service does well: The home has recently experienced a difficult time. During this period, the staff team have supported each other and have received support from the organisation. Hunters Moon DS0000064634.V362251.R01.S.doc Version 5.2 Page 6 The current staff team have a good knowledge of the needs of the people using the service; many of them are long serving staff that know the people living at the home very well. The home was found to be clean and tidy and in good decorative order. A new extension has provided additional communal areas where people can choose to be alone if they wish. Managers are very transparent about any incidents that occur including the reporting of these under the local safeguarding adults protocols. What has improved since the last inspection? What they could do better: General record keeping could be improved to include more detail and provide the reader with an audit trail. Information needs to be easily accessible, with all staff knowing where documents can be located. Risk assessments need to be kept under review and reflect the person’s individual care plan. Care plans should record peoples’ assessed need in relation to activities and leisure pursuits. Hunters Moon DS0000064634.V362251.R01.S.doc Version 5.2 Page 7 Following an initial assessment of the person’s needs, the company must write to each person, to confirm whether the home can or cannot meet their needs. Any restrictions of liberty, freedom of choice or power to make decisions including behavioural interventions for the purpose of managing challenges, must be agreed as part of a multi disciplinary assessment and recorded in the person’s care plan. Any behaviours, which may challenge must be recorded with sufficient detail to enable an evaluation and provide a clear link to the behavioural management plan and the individual’s assessed needs. Care managers should be sent copies of any Regulation 37 forms and be kept informed of any other incidents relating to their clients. The service users guide could be further developed in more appropriate formats to meet people’s needs. Staff must make sure that there are no gaps in the medication administration record. The home must ensure a permanent full time manager is appointed. An application to register the manager with us must be submitted without delay. Environmental risk assessments need to be accessible for inspection. 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. Hunters Moon DS0000064634.V362251.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 Hunters Moon DS0000064634.V362251.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): NMS 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. While there have been no new people to the service, the organisation’s admission policies would be adhered to, to ensure appropriate placements. Although the home has a statement of purpose, consideration should be given to ensuring it is in an accessible format. The service user guide needs to be reviewed and updated to suit each individuals needs EVIDENCE: There have been no new admissions to the home since the last inspection. It was therefore not possible to look at the admission process in practice. At the last key inspection, this outcome was judged as good. There has been no information to conflict with this view. Based on this, we have made a judgement, that the assessment process would ensure the service could meet the person’s needs. There is a Statement of Purpose is in place although consideration should be given to ensuring it is in an accessible format. There was no evidence available to indicate that each person living at the home had an individualised service user’s guide. Again consideration should be Hunters Moon DS0000064634.V362251.R01.S.doc Version 5.2 Page 10 given to ensure the guides meet the needs of the individual and provide them with sufficient information about the service. Hunters Moon DS0000064634.V362251.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): NMS 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care records do not give staff enough guidance to enable them to meet people’s emotional and mental health care needs. Staff try to involve the people they support and their representatives in day–to–day decision making although this is an area that could be further developed. EVIDENCE: As part of the inspection process two people were case tracked. Each person had a care plan in place, although they were not located in case files They were found in a separate file. The manager explained that the deputy and herself were currently “working their way through” all case files to ensure that they contained current and relevant information. Staff report that they have not received training in Person Centred Planning. It is recommended that training be sourced for some, if not all of the staff team to provide further awareness and consideration when they develop care plans. Hunters Moon DS0000064634.V362251.R01.S.doc Version 5.2 Page 12 The AQAA states that individual plans have been developed using pictures and photographs and other formats, however these were not available to sample at the time of our visit. Although there is evidence that the plans are regularly reviewed, the content does not provide the reader with sufficient information to ensure that peoples’ needs can be met. Staff members told us that monthly review meetings take place with the key worker and also the co-key worker. The meetings provide an opportunity to monitor people’s health, social and care needs. The minutes from one person’s review meeting showed there had been twelve incident forms completed for the month of March, relating to the person. However, these incident forms could not be located. The home must ensure that there are audit trails in place and that all staff are aware of the systems for recording and storing information. The manager agreed that the recording and storing of information is the first area that she will be addressing. Staff have implemented a behavioural management plan for people using the service. This details what steps are to be taken in the event of a person becoming distressed. The community nurse visits the home regularly and provides support to the staff team. The manager commented that when they next visit, she would ask them to read through the plans and sign them if they agrees with the content. It was noted that one person’s incident form described an incident that took place in the home’s vehicle. The incident form did not provide the reader with sufficient information to demonstrate that their agreed behavioural plan had been followed. The incident form should clearly state timescales and outcomes for the person involved. Again, staff need to understand the importance of clear, concise recording to safeguard themselves and the people they support. Greater emphasis needs to be placed around the communication needs of the people using the service. Staff confirmed that they often rely on their knowledge of the people they support, when assisting people to make decisions, for example when choosing food to eat. We discussed how this area could be further developed with the use of communication tools such as communication boards and passports, which will encourage people to make decisions in their lives. We identified people who may benefit from having menus or pictures of meals available to aid their choice making. Records showed that picture cards had been used successfully in the past for one person. They are no longer used. Case review notes also suggest that the person may have some knowledge of Makaton signs, although their care plan does not record this as a alternative mode of communication. The deputy manager explained how people are to be involved in the decorating of the new extension. He reported that people liked using the little tester pots Hunters Moon DS0000064634.V362251.R01.S.doc Version 5.2 Page 13 of paint and that everyone will have the opportunity to participate in the activity. Risk assessments is an area that needs some attention both in ensuring all risks have been considered for each individual living at the home but also in demonstrating that they have been kept under review. Where there are no changes to risk assessment, staff need to show when they were reviewed and be signed by the person carrying out the assessment. One person had a risk assessment in place that placed a restriction on them. It is recommended that this restriction be agreed by a multi disciplinary team and not just by the person who carried out the assessment. This was discussed during feedback with the manager who reported that she was planning to ask the community nurse to confirm their approval of the assessment. It would be good practice to also involve the care managers and relatives. Hunters Moon DS0000064634.V362251.R01.S.doc Version 5.2 Page 14 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): NMS 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are now more opportunities for education and leisure pursuits available to the people living at the home. Links with relatives and friends are encouraged. EVIDENCE: Since the last inspection there appears to be an improvement in the leisure and educational opportunities available for the people using the service. Each person has an activity programme. Activities include swimming, trips to the cinema, shopping, lunch out, drives in the car, walks and foot spas. Some people attend College, where they attend performing arts or drawing classes. The home as an electric keyboard, which staff report, is popular with some people living at the home. Plenty of board games are available along with a television and DVD’s. Music centres are available and there is also a karaoke machine for people to sing along with if they wish. Hunters Moon DS0000064634.V362251.R01.S.doc Version 5.2 Page 15 The AQAA states that people are part of the local community and that all of the people using the service use the local facilities such as the pub, shops and local doctors surgery. Entries in the diary show that people go out for walks locally and also go to the local shops to purchase items. The home supports people to maintain relationships with families and friends. Many people visit their family at the weekend on a regular basis. The diary did not indicate what activities take place for the remaining people. The four weekends prior to the inspection did not appear to have any activities planned for. Nor was there evidence in the diary to show that any spontaneous activity had taken place. The ratio of staff on duty should enable staff to take people out and about. People have the opportunity to attend the PHAB club on a Thursday evening and the Gateway club on a Wednesday evening if they wish. Staff report that one person has chosen to go to Butlin’s for their summer break this year. Staff members report that some people help with food preparation and some general household tasks such as hovering and dusting. One person commented that they like to make cakes on a Friday. The manager confirmed that currently no one has a key to his or her room. There did not appear to be any assessments on the case files to indicate how this decision had been made. Mealtimes appear to be pretty flexible taking into account people’s routines and daily activities. Staff were observed supporting people with their meals in an unhurried, relaxed manner. Interactions between staff and the people they support were positive. Staff reassured people and included them in conversations. It was noted in one person’s review notes that they were advised that food was cut up small to make it easier for them to swallow. There did not appear to be a risk assessment in place to minimise any potential risk of choking. The main meal of the day is taken in the evening, with lunch being a snack. The menus were sampled and appeared healthy and balanced options. The AQAA states that all meals served are home cooked. The staff commented on the problems they were experiencing with the cooker. They reported that it is very temperamental and sometimes the rings or the oven does not work. They added that this could sometimes cause meals to take a long time to cook. We discussed this with the manager who confirmed that the home have recently employed a new maintenance man who is a qualified electrician. She said she would report the fault to him straight away. Hunters Moon DS0000064634.V362251.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): NMS 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s physical needs are met although care records do not give staff sufficient information and guidance to ensure they meet their emotional needs. Generally medication is managed well although unexplained gaps on the Medication Administration Records (MAR) could place people at risk. EVIDENCE: Evidence shows that the people using the service have access to healthcare professionals such as consultant psychiatrists, doctors, community psychiatric nurse, optician, dentist and chiropodist. As mentioned earlier in this report, care plans could be further improved by providing the reader with more detailed information relating to daily routines and how personal support is offered. One person has protocols in place for the management of their Epilepsy. These were completed by the community nurse in 2006 and had been reviewed in March 2007. Another person had protocols in place for the management of their seizures dated 6/12/05. There was no evidence to demonstrate that the protocols had been reviewed since then. Hunters Moon DS0000064634.V362251.R01.S.doc Version 5.2 Page 17 Records show that the consultant psychiatrist regularly visits the people living at the home and offers support and advice to the staff team. One care manager told us “for the most part, I feel ok with things at the home, although they do not always keep us informed of issues relating to our clients, such as when they go to hospital for tests”. They added that the homes’ recording systems could also be further improved. A recommendation was set at the previous inspection stating that when reporting incidents under Regulation 37 of the Care Homes regulations 2001, copies of such incidents affecting people who use the service should be copied to the person’s care manager. The care manager we spoke to confirmed that this was still not happening. Discussion with the home’s manager confirmed she had always ensured this practice was carried out at her past placement and would be implementing this at Hunters Moon. The AQAA states that some people using the service are currently under review from the consultant psychiatrist with the aim of reducing any behaviour modifying medication. No one living at the home currently uses ‘ as required’ (PRN) medication for behaviour control. The manager confirmed that the home is continuing to develop health action plans for each person using the service. It was recommended at the last inspection that the home obtains and uses a dedicated health assessment tool so that information about health care needs can more easily be separated from other information kept in the home. This was discussed during feedback with the manager. As part of the inspection process we looked at the arrangements for managing medication. Staff members confirmed that they had received training in the administration of epilepsy medication, the use of insulin and had attended a general Epilepsy training course. One person told us they had attended Swindon College for medication training and that they had also covered medication as part of their induction. Staff members are provided with a workbook, which covers medication after they have completed the ‘Foundation in Care’ workbook. Only staff that are trained and deemed competent administers medication. Medication is securely stored in the home. We sampled the MAR sheets and found that there were many unexplained gaps. Care needs to be taken to ensure that records are completed correctly as some medication comes in liquid form, which makes it difficult to ascertain whether the medication had been given or not. Hunters Moon DS0000064634.V362251.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): NMS 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Any complaints are listened to and acted upon promptly. People using the service are safeguarded by a staff team who have a sound understanding of the local protocols for reporting any allegations of abuse. EVIDENCE: The home has a complaints procedure in place, which is in a pictorial format. It was noted that the contact details for the Commission were incorrect. The deputy confirmed that the home has a complaints log, which records timescales and outcomes of complaints. This could not be located. The deputy manager told us that it might have been amongst the documents removed by the police for their investigation. The AQAA states that key workers have explained to the people they support how to raise a concern if they need to. Staff members confirmed that they know the company’s procedure for making a complaint. There is currently an on-going safeguarding investigation taking place, which has been conducted under the local ‘No Secrets’ procedures. Staff confirmed that have received training in the Protection of Vulnerable People and have a commitment to working with the police in the Vulnerable Adult unit. Staff members told us that they have also covered safeguarding protocols whilst completing their National Vocational Qualifications (NVQ). Hunters Moon DS0000064634.V362251.R01.S.doc Version 5.2 Page 19 The home has a policy and procedure in place for safeguarding people, which is in line with local protocols. All monies held on the premises for the people living at the home are checked at each handover. Only the manager, deputy and seniors have access to the money tins. We checked two randomly picked money tins and the record sheets. Both tins and records balanced. Hunters Moon DS0000064634.V362251.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): NMS 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. EVIDENCE: The home has recently had an extension added to the premises, which has provided more communal space for the people living at the home. There is also a conservatory, which has comfortable chairs and a beanbag for people to sit on. There is also a bubble lamp in the conservatory. Staff report that one person particularly enjoys sitting in this area on their own. The home provides plenty of space for people not to feel restricted and enables them to have their own space if they wish. Concerns identified at the last inspection regarding the worktop between the dining room and the kitchen area have now been minimised by the repositioning of the dining table. Hunters Moon DS0000064634.V362251.R01.S.doc Version 5.2 Page 21 Bedrooms and bathrooms were found to be clean, tidy and hygienic. All areas were found to be in good decorative order with matching furnishings and fittings. People have personalised their bedrooms with photographs and pictures. All windows are fitted with restrictors and radiators are covered and fitted with thermostat controls, to protect people from injury. The home has a separate utility room, which houses the washing machine and drier. Staff confirmed that the washing facilities are suited to the needs of the people using the service. Staff members were observed wearing protective clothing whilst they were preparing food. Throughout the home there were supplies of disposable gloves and antibacterial hand wash. Staff report that they receive training in Infection Control. The AQAA states that they are planning to upgrade both the utility room and the downstairs bathroom over the next twelve months. They are also planning to convert shower rooms into ‘wet’ rooms to enable people to use them safely. Hunters Moon DS0000064634.V362251.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): NMS 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. Staff are properly recruited, trained and supervised. EVIDENCE: Some people living at Hunters Moon require 2-1 staff support at all times. During our visit we witnessed this being adhered to, with staff members ensuring that when a member of staff was talking to us, another person replaced them. We had the opportunity to meet with two staff in private and meet others in the communal areas. The manager explained that they currently using agency staff to cover any staff vacancies. One agency member of staff told us that they are included in team meetings and feel very much part of the team. They confirmed that they have a good understanding of the needs of the people living at the home. They confirmed that they usually have one to one supervision from the agency. Hunters Moon DS0000064634.V362251.R01.S.doc Version 5.2 Page 23 Staff confirmed that they received an induction when they started working at the home. One person said they had spent three days in the head office going through policies and procedures. All new staff receive one full week of formal training, which covers all mandatory courses such as First Aid, Moving and Handling (theory), COSHH, Basic Fire Awareness, Equality and Diversity, Learning Disabilities, Protection of Vulnerable Adults, Mental Capacity Act and an introduction to autism. As mentioned earlier in this report, staff are then enrolled for a distance learning course in ‘Foundation to care.’ They are allowed three paid days to complete it. All staff are required to undertake a 3 day Positive Behaviour Management Course, which helps them to understand why people sometimes exhibit challenging behaviours and how best to work with people who are showing signs of distress. All staff are required to undertake epilepsy and diabetes training. The monthly management reports, which are submitted to us confirm that during a recent audit of all the personnel files held at the home it was discovered that several files did not contain the necessary information. On the day of the our visit the manager explained that they were intending to send all personnel files to the head office so that any missing information could be added. We sampled three staff recruitment files. We found one had unexplained gaps in their employment history One did not have a satisfactory Criminal Records Bureau check number although the cover sheet stated that it had been received. Overall, records indicated that staff are recruited properly and all relevant checks are carried out. Hunters Moon DS0000064634.V362251.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): NMS 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The absence of a registered manager has impacted negatively on the service. Mechanisms are in place to obtain the views of people who may have an interest in the home. Health and safety practices are carried out to provide a safe environment for the people. EVIDENCE: The home has been without a permanent manager for over twelve months. An experienced manager who has been seconded from another Holmleigh service is currently covering the position until a new manager is recruited and appointed. The home has recently recruited a new deputy manager. One staff member reported that the appointment of the deputy ‘has made a difference’. The manager has already identified many areas that need attention and is working with the deputy to address them. It would appear that things have ‘slipped’ a little in the absence of a full time manager. Hunters Moon DS0000064634.V362251.R01.S.doc Version 5.2 Page 25 The manager commented that she has plans to get things back on track whilst she is in position and ensure things are running smoothly for when the new manager starts. The registered provider confirmed that Quality Assurance audits are completed twice a year with the next one being due in June. The views of relatives, care managers and health care professionals are sought. Monthly management audits are completed and submitted to us. A recommendation was set at the last inspection relating to the content of the reports. This has now been addressed with the reports being more narrative and including both critical comments as well as areas considered being satisfactory. It was noted that the last report we received had not been signed and dated by the person completing it. Evidence shows that health and safety checks are regularly completed. This includes recording the temperatures of the hot water and fridge/freezers. All toxic materials were securely locked away, with the corresponding data available. The home has a fire risk assessment in place although it was not dated. Regular checks on fire fighting equipment are carried out and staff receive regular fire instruction. There is a current portable appliance check in place. The manager could not access the gas safety certificate but felt confident that this would be held at the head office. We were unable to locate any environmental risk assessments. The manager reported that she was sure they would be in place but she was unsure where they would be kept. Hunters Moon DS0000064634.V362251.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 N/A 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 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 2 2 X 2 X 3 X X 2 X Hunters Moon DS0000064634.V362251.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 YA20 Regulation 13(2) Requirement The registered person must ensure that any gaps on the medication administration records are explained. The registered person must ensure that a risk assessment is completed for any individual who may be at risk of self-harming. The registered person must ensure that a risk assessment is completed for any person who may be at risk of choking. The registered person must ensure that a risk assessment is completed for any person who could be at risk when travelling in a car. The registered person must ensure that any incidents are fully recorded detailing the intervention used, timescales and outcomes. The registered person must ensure that a system is in place to provide an audit trail of all recorded incidents, which are easily accessible. The registered person must ensure that all risk assessments are kept under review and are DS0000064634.V362251.R01.S.doc Timescale for action 24/05/08 2. YA9 13(4)(a, b, c) 13(4)(a, b, c) 13(4)(a, b, c) 24/06/08 3. YA9 24/06/08 4. YA9 24/06/08 5. YA6 15(1) 24/06/08 6. YA6 15(1) 24/06/08 7. YA9 13(4) 14(b) 24/06/08 Hunters Moon Version 5.2 Page 28 signed and dated. 8 YA1 5(a-f)(2) The registered person must ensure that each person living at the home has a copy of the service users guide in a format, which makes sense to him or her. The registered person must ensure before a person is placed in the home and following an assessment of their needs, the company must write to the person and confirm the extent to which the home can or cannot meet the persons needs. This requirement remains unmet, as there have been no new admissions. The registered person must ensure any restrictions of liberty, freedom of choice or power to make decisions including any behavioural interventions for the purpose of managing challenges, must be agreed as part of a multi- disciplinary assessment including, where relevant, by a competent behavioural specialist and/or psychologist or psychiatrist and recorded on the persons care plan. This requirement remains unmet in full within the timescale 05/12/07. Those undertaking monthly management reports as to the conduct of the home must ensure such reports are dated and signed by the person undertaking such reports. This requirement remains unmet within the timescale 05/12/07. The registered provider must ensure that a registered manager be appointed as soon as is possible. 24/07/08 9. YA3 14(2) 24/06/08 10. YA2 12(1)(b) 24/06/08 11. YA39 26(4) 24/06/08 12. YA37 8(1)(a) 24/07/08 Hunters Moon DS0000064634.V362251.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 Consideration should be given to the service user guide being in an audio and pictorial format that is suited to peoples’ needs. Unmet from previous inspection. When reporting incidents under Regulation 37 of the Care Homes Regulations 2001 copies of such incidents affecting people who use the service, should be copied to their care manager. Unmet from previous inspection. It is recommended that communication tools be further developed to enable people to make more choices. It is recommended that staff members have the opportunity to attend Person Centred Planning training. It is recommended that care plans are further developed to provide the reader with sufficient information about the person’s needs including their communication needs. It is recommended that opportunities for weekend activities be monitored to ensure that the people who remain at the home have access to leisure pursuits if they wish. It is recommended that key workers undertake a monthly audit of the activities that users of the service take part in which also shows what they do, how often and who with. Unmet from previous inspection. It is recommended that the oven be repaired or replaced as soon as possible. It is recommended that all environmental risk assessments are made available for inspection and for staff reference. It is recommended that the home ensures that care managers are kept informed of events affecting their clients. It is recommended that staff attend a more comprehensive manual-handling course. It is recommended that the fire risk assessment be dated. It is recommended that the home keeps a complaints log to enable them to identify any patterns or trends that may arise. It is strongly recommended the home obtains and uses a dedicated ‘health action assessment tool’ so that information about health care needs can more easily be DS0000064634.V362251.R01.S.doc Version 5.2 Page 30 2. YA2 3. 4. 5. 6. YA6 YA6 YA6 YA12 7. YA12 8. 9. 10. 11. 12. 13. 14. YA42 YA42 YA19 YA42 YA42 YA22 YA19 Hunters Moon separated from other information kept at the home. Unmet from previous inspection. Hunters Moon DS0000064634.V362251.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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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