Inspection on 21/06/07 for Intelligent Care

This inspection was carried out on 21st June 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 no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Intelligent Care 30/10/08

Intelligent Care 05/06/08

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

CARE HOME ADULTS 18-65 Intelligent Care 102 Park Road Bolton Lancashire BL1 4RQ Lead Inspector Stuart Horrocks Unannounced Inspection 21st June 2007 09:30 Intelligent Care DS0000069171.V337257.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 Intelligent Care DS0000069171.V337257.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. Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Intelligent Care Address 102 Park Road Bolton Lancashire BL1 4RQ 01282715175 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) Jamil Mohammed Miss Nusat Khan Mr Akeel Mohammed Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home only - code PC, to service users of the following gender:Female Whose primary care needs on admission to the home are within the following categories: Mental disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 6 Date of last inspection N/A Brief Description of the Service: Intelligent Care is a privately owned organisation that provides residential services in a care home called Queens Park View that is situated in a residential area of Bolton close to Bolton School. Queens Park View is a large three-storey Victorian style property with mature gardens to the front and back. The front of the property overlooks Queens Park which is a very popular landmark of Bolton with the home being located near to the town centre in a quiet residential road set back in an elevated position. The building has been fully refurbished with a large lounge, a further lounge/dining room and a kitchen. There are six bedrooms, two of which have en-suite facilities. The other bedrooms have washbasins with vanity units and all bedrooms have TV points. Toilets and showers are available on the ground and first floors. There is limited car parking to the front of the home and on street parking is also available. The Statement of Purpose says that the aim of Intelligent Care is to provide client centred rehabilitative care for people between 18 and 65 years of age who have mental health problems with the intention of enabling them to live independently or semi independently within the community. The home is currently registered for the care of female residents only, although the owners are in the process of altering this registration so that both male and female service users can be accommodated. A Service User Guide, Statement of Purpose and a leaflet style brochure that describe the home’s services is available in the home and the provider gives other information about the home to new and prospective residents and their families verbally. As of June 2007 the weekly charge for accommodation and services is £500.00 with an additional charge being made for personal hairdressing and chiropody Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 5 services. Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection, which included a site visit that was started at 9.30am on the 21st June 2007. The home did not know that the inspector was going to vist. It took place over one day and it lasted for about nine hours. The time was spent between talking to the two owners, the manager, and checking records, looking around the home, watching what was happening and talking to a resident, and one member of the staff. The home was first registered in March 2007; this was therefore the first full inspection of the home since registration. One person had been admitted to the home shortly before this visit with this person being the only resident accommodated at the time of the inspection. The inspection therefore focused upon this persons care with this being the basis for the process of the inspection. However the reader should bear in mind that the fact that with only one resident living at the home this report may not fully illustrate the way that the home operates, which will probably be better portrayed at following inspections when the home will hopefully be fully occupied. A completed provider’s self-assessment survey information document (Annual Quality Assurance Assessment) was received before the inspection along with four feedback surveys. What the service does well: What has improved since the last inspection? Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 7 This was the first inspection of the home so this section of this report does not currently apply. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Intelligent Care DS0000069171.V337257.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 Intelligent Care DS0000069171.V337257.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 and 2. Quality in this outcome area is good. Pre-admission visits, and the initial assessment process, enable all parties, including potential residents and their relatives, to reach a decision as to whether the home will be able to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home as is required has developed a generally satisfactory Service User Guide (Residents Information Guide) and a Statement of Purpose. Both of these documents provide prospective residents and their families with useful and valuable information about the care and services provided by the home. However, these documents are not entirely accurate due to changes that have occurred since they were written. The home has admitted a male resident although the registration allows for the admission of female residents only. As mentioned previously the owners now intend to apply to have the registration status changed to allow for the accommodation of residents of both sexes. The Registered Manager intends to leave the home within the next few months with one of the owners intending to take over this role. (Further information regarding these issues can be found under Standard 37 later in this report). It is due to these changes that the Statement of Purpose and the Service User Guide will need to be amended. Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 10 There is an expectation that new residents will have had their care needs assessed before they move in to the home so that both they and the service can be confident that the home can meet their needs. Such assessments are usually provided by the referring agency (e.g. a Social Services Department) or in the case where residents are paying for their care by the home’s assessment procedure. The home has both written criteria for admission and for the making of referrals. The care file of the resident recently admitted to the home was therefore checked for the required pre-admission needs assessment information. Such assessments were seen to be in place that demonstrated that the admission procedure was very thorough and checking of the above records showed that a full and detailed assessment of this resident’s care needs had been completed prior to their admission to the home. The inspector was informed that all new residents have an in-house preadmission needs assessment done no matter who is paying for their care. Evidence of this was seen in the above checked care file. From the above information the home is then able to assess whether these people’s needs can be met and a care plan, a care programme and a range of other care delivery information is then put together. The manager usually visits new residents either at home or in the hospital as a part of the assessment and admission process. The inspector was told that new residents and their families are welcome to visit the home where they can spend some time, meet the residents and the staff, and have a meal before deciding to live there. This visiting opportunity is described in the useful and informative Service User Guide (Residents Information Guide). The person in residence had visited the home on a number of occasions before moving in on a full time basis and they were then admitted for a four-week trial period during which the suitability of the placement will be assessed. A client placement agreement (a contract of residence) had been put in place between the home and the placing authority (Bolton Social Services Department). Intelligent Care DS0000069171.V337257.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 and 9. Quality in this outcome area is good. A high quality of care delivery information is available, residents are encouraged and assisted to make decisions and choices and detailed risk management information is available although the home needs to reinforce this by implementing the “in-house” processes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care file of the one resident accommodated was checked for the required care planning, care delivery and care recording information. A care plan had been put together that dealt with this person’s health, social and personal care needs. This plan was person centred, set clear goals and was aimed at addressing this person’s mental health and rehabilitative (including decision making) needs. It was in line with the home’s stated aims and objectives and supported the resident in living an ordinary and independent lifestyle and was aimed at aiding their recovery and eventual inclusion within the local community. Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 12 Decision and choice making is included in the care package and this is actively encouraged and supported by the care staff as a necessary and essential part of the resident’s rehabilitative process. It is intended that this care delivery programme will be reviewed quarterly or more frequently as the residents needs and progress may require. The information was well laid out, easy to follow and contained details raised by both the home and the referring NHS agency. Progress reports were regularly recorded that demonstrated the development of the resident’s personal daily living skills and the achievement of goals. Very detailed risk assessment information has been provided by the referring agency that covered personal risk and for activities that the resident is involved in both inside and outside of the home. They describe the management and the support needed for each sort of risk and activity. The home has a detailed “in-house” risk management action plan but this had not been completed and now therefore must be brought in to use so underpinning the above described and provided information. The one resident accommodated has a weekly amount of money provided that is given to him in equal daily amounts. This money is safely kept and the distribution of this money is presently recorded in a shorthand notebook. The amount of money held corresponded with the figure recorded in the abovedescribed record. However in order to protect the interests of both residents and staff these records need to be improved so that they comprise a full credit and debit account with spending described, a running balance kept and signatures applied. It should be noted that the home has purchased a number of hardbacked books that are to be used individualy for the recording of transactions of residents’ monies. Intelligent Care DS0000069171.V337257.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): 12,13,15,16 and 17. Quality in this outcome area is good. The resident is, and others will in the future be encouraged and supported to take part in activities that provide interest and purpose in their lives and enables them to be a part of the local community. Family and community contact is facilitated that helps the residents to have personal relationships and the resident’s health is maintained by the provision of proper meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In relation to the above standards the home’s Service User Guide describes the provision of meaningful activities that are needs led that will encourage residents to take part in or pursue any hobbies or interests that they may have, either with or without staff support. A socially inclusive model of working is described that will support residents in accessing college courses or training and full or part time paid or voluntary employment, to further promote the individuals recovery or independence. This document also states that residents will be encouraged and supported to Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 14 pursue their religious beliefs and that transport will be provided to allow residents to access local amenities. The resident presently living at the home is currently unable to be employed or involved in any form of training but he does go out of the home accompanied for walks and shopping and has retained an interest in football. A weekly activities programme has been put together for this person that is mainly rehabilitative in nature i.e. cooking and menu planning and the safe use of kitchen appliances. The inspector had a brief discussion with the resident, which showed that they were still in the process of settling in to the home, that they were comfortable living there, that they got on well with the staff and that they felt safe. Residents are encouraged to keep up contact with family and friends, which can be done by ‘phone, e-mail or by direct visits to the home. Residents can see visitors in their bedroom (following risk assessment and agreement) for privacy or in any of the lounges. Both residents and visitors are encouraged to take part in the day-to-day running of the home where this considered appropriate. Due to the fact that only one resident is presently living at the home no food menu is in place or is at this time considered to be necessary. Currently meals are decided on an individual basis and they are often prepared by the resident with staff assistance and support as a part of the therapeutic programme. However a record of the food provided is kept that showed that a nutritious, varied and attractive fare is made available. The inspector was informed that the home intends to introduce a regular menu as more residents come to live at the home. The resident told the inspector that they were satisfied with the diet and that they enjoyed this. The satisfactory nutritional status of the resident is currently assessed by direct observation and by the record of the food and drinks taken. This must be further reinforced by the use of regular and recorded weight checks and the inspector advised the staff that specific nutritional written risk assessment tools are available should these be needed if dietary problems are encountered. Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is adequate. Although personal support is provided in a dignified and respectful manner and the residents’ health care needs are suitably dealt with, the home’s medication arrangements need to be improved so ensuring that the people living at the home receive their medicines as prescribed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The resident’s care documentation included information about how personal care and support is to be offered and that this is done in a way that residents prefer with this following the guidelines described in the home’s Statement of Purpose and Service User Guide. This includes supporting resident’s personal hygiene and daily living tasks and ensuring that clothing, hair care and general appearance is appropriate and that this enhances their dignity. The resident told the inspector that the routines of the home are flexible, which includes mealtimes and the times for getting up and going to bed and how they spend their time within the structure of their care programme. From talking to the staff and the examination of documentation is was clear that the resident has full access to all aspects of NHS care services and that Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 16 their health care is properly monitored including regular support from the local NHS mental health services. Suitable secure storage is available for the keeping of resident’s medicines. Only one medication was in use at the time of the inspection with this having been properly recorded on the resident’s medication administration sheet. Medication prescriptions are currently handwritten by the staff on the medication administration sheet. Care must be undertaken when writing these out to ensure that no errors are made and another member of staff should witness this task with the record being countersigned by them. Medicines received into and leaving the home are presently not recorded, therefore no audit trail of the safe handling of these is kept. The home has a medication policy that includes information about the selfadministration of medicines. However this policy must be amended so as to include reminders for the staff to check whether the dose of medicine has already been given, that the correct dose is being offered and that this is at the correct time of administration. The home does not currently have any facilities for the storage or recording of Controlled Drugs. Should such drugs be brought in to use then such storage and recording facilities will need to be acquired. Of the five care staff employed at the home three of these have done medicine administration training, the home must ensure that only those staff who have undertaken such training give out medicines. The inspector recommends that good practice should be followed with photographs of each resident being kept with the medicine administration records as an aid to safe identification. The inspector was informed that the home is currently giving consideration to the use of The Boots Monitored Dosage System. This system usually provides pre-filled blister packs of medicines, pre-printed medicine prescription/administration records and may provide a medicine storage cupboard. Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. Although the home has a clear complaints system that should ensure that concerns are properly dealt with, the lack of protection of vulnerable adults guidance and the partial lack of staff training in this topic puts residents at risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a good complaints procedure that states how a complaint is to be made, who to and that an initial response will be provided within two days with a final outcome forwarded within 28 days. The facility of making concerns known directly to the CSCI is also included in this paperwork although this needs to be changed to show the relatively recent move of CSCI office location and telephone number. Discussion with the one member of staff interviewed demonstrated that they were aware of the home’s complaints procedure. They showed that they would know what to do if a complaint was made and they said that they would assist residents in making their concerns known. The home should ensure that residents and their relatives are made fully aware of the home’s complaints procedure so that these people will be confident, when necessary in making their concerns known and that they will be listened and responded to. No complaints have been made either to the home or to the CSCI since the home was registered in March 2007 The home is required to keep a record for the listing of any complaints that may be made. Such a record was available but this needs to be improved so that the details recorded will include the date of the complaint, the name of the Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 18 complainant, the nature of the complaint, and of the outcome and actions taken. Standard 23 requires that the home must ensure that residents are protected from abuse, neglect and self-harm with systems, policies, procedures and staff training being in place to facilitate this. Although a statement regarding these issues is present in the home’s Service User Guide and the home has “whistlblowing” staff guidance, no comprehensive written Adult Protection Procedure is separately available. Such a procedure must therefore be formulated, when necessary implemented and the staff must be made familiar with this process. The inspector also recommends that a copy of the Bolton inter-agency Safeguarding Adults Policy be obtained so that local procedures can be followed should an abuse situation arise in the future. Discussions with the member of staff showed that this person had a good understanding of adult protection issues and examination of records showed that some staff had received training in this topic. The home must however, ensure that all of the staff are provided with training in adult protection subjects so that the residents are protected from harm. Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is excellent. Queens Park View is well maintained, comfortable and clean, providing service users with an environment that is inviting, homely and pleasant to live in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As mentioned previously the home has recently been fully refurbished with this work having been completed to both a high standard and a high specification. The building is generally well maintained to both the inside and to the outside. Queens Park View is bright and welcoming. Decoration, furnishing and lighting in communal areas and bathrooms is to a high standard and is domestic in style. All of the bedrooms were checked and were found to be decorated, furnished and equipped to a high standard and the resident said that they were satisfied with the level of the accommodation provided. The home has a well-equipped kitchen that was being used to assist the resident in developing cooking and menu planning skills and in the safe use of kitchen appliances. Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 20 The laundry is situated in a semi-basement area and information regarding the control of infection is available. The home was found to be very clean and tidy throughout and was free from any offensive odours therefore providing a pleasant place to live. Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34 and 35. Quality in this outcome area is poor. Failures in safe staff recruitment means that residents may not be fully protected, the management arrangements are not entirely satisfactory and staff training needs must be assessed with any shortfalls being addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection the home was employing three permanent and two “bank” care workers. Examination of a four week rota for the period from the 11th June 2007 showed that one care worker was on duty from 8am to 10pm and that one person “slept in” overnight with on call support being available at all times. The registered manager provides support in the evening, overnight and at the weekend (please see Standard 37 regarding this situation) and the home’s two owners regularly provide support at various times during the day and the night. Although the management arrangements are not entirely satisfactory it was agreed during discussion with various staff members that this overall staffing provision was sufficient on an interim basis to meet the needs of the one resident currently accommodated including the taking in to account of any assessed risk. Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 22 The home intends to increase the provision of staff as residents numbers rise and that this will if necessary include waking night staff. (The staff are reminded that duty rotas must show the full name of each staff member and that copies of these rotas must be retained so that if in the future and if necessary previous staffing provision can be readily checked). Examination of staff training information showed that all of the care staff has successfully completed the required NVQ Level 2 assessment and that one of these people was presently undertaking this assessment at Level 3. Staff training information is currently kept in each workers individual file. These showed that some workers had completed training for topics such as the protection of vulnerable adults and the giving of medicines but that some of the required health and safety training (moving and handling, fire safety, first aid, food hygiene and infection control) as described under Standard 42 had not yet been provided. The home has put together a staff training calendar that does include some of the above topics, but staff training needs must be assessed and where shortfalls are identified these must be addressed. The inspector and the home’s senior staff discussed the way that staff training is presently recorded. The inspector suggested that the development of a stafftraining matrix would assist the manager in seeing what training had been completed, the date it had been done and what other training the staff needed to undertake. Staff are to be provided with a seven-day social care induction-training programme that is provided by Bolton Social Services Department that covers a wide range subjects; some of the topics covered are used to contribute to the NVQ 2 Award in Care and this training complies with the nationally recognised Scils for Care Common Induction Standards. The files of all care staff were checked for the required safe employment information. These did not fully evidence a safe and proper recruitment system. All of the files contained a completed job application form, a satisfactory work history and criminal conviction declaration. But no up to date police checks were present (some having been transferred wrongly from previous employment), not all contained a health declaration and in some instances proof of identity had not been confirmed. Most, but not all had two written references although some of these were of the “to whom it may concern” type that had not been provided on official headed paper, which can raise doubts concerning there validity. The fact that all of the staff did not have up to date police or POVA First checks in place raised the issue that they should not have been working at the home, particularly lone working where they were not supervised. Following immediate consultation with a CSCI manager, it was agreed that one of the previously approved two home owners or the registered manager would be present at all times in the home until satisfactory staff police checks has been raised. The Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 23 only other option being immediate closure of the home, which would have been highly unsatisfactory for the one resident accommodated who was both just beginning to settle in and to become established on a beneficial rehabilitative care regime. The home must in the future therefore make sure that full details about workers are obtained before new staff are employed so ensuring the safety and protection of the people living at the home. Intelligent Care DS0000069171.V337257.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 and 42. Quality in this outcome area is adequate. Although the manager is well qualified to run the home his future position there is now only relatively short term and largely outside of routine working hours, which is somewhat unsatisfactory in terms of consistency in supporting both the staff and the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home manager (Mr. A Mohammed) has been previously approved and registered with the CSCI. He was heavily involved with the setting up of the home and has been responsible for the running of the home since the home became operational following the first resident admission in mid June 2007. This person is well experienced and well qualified in providing the care and services that the home is now and will in the future provide. At the time of registration in March 2007 the manager was and still is alternatively employed Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 25 with the intention that when the home became operational he would give up his then employment and become the full time manager of the home. However, he has since decided that he does not wish to leave his current employment and therefore intends to resign his post as registered manager when another manager is appointed. He is currently able to spend between 30 and 35 hours per week at the home mainly in the evening, overnight and at the weekend. This situation was discussed with one of the owners of the home (Mr, J Mohammed) who now intends to apply to the CSCI to become the registered manager of the home. Steps were taken during the inspection to initiate this process and to vary the home’s registration status so that both male and female residents can be accommodated. A requirement of Standard 39 is that care homes must use quality assurance systems that are largely based on seeking the views of residents to measure their success in meeting the home’s aims and objectives. . This information can then be used if necessary to bring about changes or improvements to the service. Care homes usually do this by the use of a survey document that asks a series of questions about the home’s services and facilities. Queens Park View has developed such a satisfaction survey document that is entitled “How was it for you”. This has not yet been used, but when more residents are living at the home this should be introduced. The staff are reminded that when this survey is used a brief report of the findings should be put together and displayed in the home. Consideration must also be given to using this survey with resident’s families and health care professionals so that their views on the operation of the home will be sought and if necessary acted upon. The inspector also suggested that internal quality audits be in the future undertaken for items such as care plans, the medication regime, building cleanliness and maintenance and health and safety. Information obtained from the provider’s self-assessment survey information document (Annual Quality Assurance Assessment) and checking of records showed that the home’s fittings, fixtures and equipment is properly and safely maintained. The home has an appropriate record for the writing down of details of accidents but this has not yet needed to be used. Examination of the home’s fire precautions log showed that the fire detection and fire fighting equipment had all been checked and tested recently. The staff are reminded that these tests must be carried out and recorded at the intervals shown in the home’s Greater Manchester Fire and Rescue Service log. As mentioned previously under the staffing standards staff health and safetytraining needs must be assessed with any shortfalls being dealt with. Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 26 Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 27 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 1 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 3 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 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 3 2 X 2 X 3 X X 2 X Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? N/A 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 YA1 Regulation 4 (1) 5 (1) Timescale for action The home’s Statement of 31/08/07 Purpose and the Service User Guide must be updated so that accurate information about the home’s services is available to all interested parties including prospective residents and their families. Transactions of residents monies 20/08/07 must be properly recorded so protecting the interests of both residents and staff. In-house risk assessments must 20/08/07 be used to ensure that risks to both residents and staff are properly managed. Resident’s body weight must be 20/08/07 regularly monitored as a means of checking their nutritional status and general wellbeing. The home’s medication 20/08/07 arrangements and policies and procedures must be reviewed so ensuring that the people living at the home are given their medicines as prescribed. A proper record of any 31/08/07 complaints made must be kept at the home, so that the level and nature of any complaints DS0000069171.V337257.R01.S.doc Version 5.2 Page 29 Requirement 3 YA7 17 (2) 3 YA9 13 (4) (b) (c). 12 (1) (a) 4 YA17 5 YA20 13 (2) 6 YA22 17 (2) Intelligent Care 7 YA23 13 (6) 8 YA34 19 (1) (b) 9 YA35 18 (1) (c) (i) made can be monitored and if necessary any issues addressed. Residents interests and rights 31/08/07 must be protected by the development of adult protection policies, procedures and training. Staff must be safely and properly 20/08/07 recruited with all of the required checks being completed before they are employed, to ensure that workers who are suitable and fit to do this work care for the people who use the service. Staff training needs must be 31/08/07 assessed and where shortfalls are identified these must be addressed so making sure that the residents can be confident of receiving a good standard of care. 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 YA23 Good Practice Recommendations It is recommended that a copy of the local Safeguarding Adults Policy is obtained so that local guidance is followed should an abuse situation arise. Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Intelligent Care DS0000069171.V337257.R01.S.doc Version 5.2 Page 31 - 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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