Inspection on 14/09/06 for Karamea Care Homes

This inspection was carried out on 14th September 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Karamea Care Homes 28/09/07

Karamea Care Homes 07/11/05

Karamea Care Homes 03/05/05

Karamea Care Homes 13/01/05

Karamea Care Homes 12/07/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Karamea Care Homes, 1 & 2 Church Mews Church Street Theale Reading Berkshire RG7 5BZ Lead Inspector Stephen Webb Unannounced Inspection 14th September 2006 12:30 DS0000011211.V305721.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 DS0000011211.V305721.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. DS0000011211.V305721.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Karamea Care Homes, 1 & 2 Church Mews Address Church Street Theale Reading Berkshire RG7 5BZ 0118 930 3695 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) Mrs Debbie Dickinson Miss Teresa Bieny Care Home 8 Category(ies) of Learning disability over 65 years of age (8) registration, with number of places DS0000011211.V305721.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2005 Brief Description of the Service: Church Mews currently provides care for six adults with a learning disability, though it has existing bedrooms for seven, and is registered for eight. The home is set back from the main road, in a residential area close to local amenities and the town centre, and comprises two adjacent houses. Both houses are on two floors and there are some aids and adaptations in the bathrooms to allow residents to move about more independently. One house accommodates four residents, the other has two at present. The residents sometimes spend time together as a group, and at other times remain in their separate houses. Each has its own kitchen, dining room and lounge. Some meals are made collectively and others within the individual houses. All of the bedrooms are single and some of them have en-suite facilities. There is one communal toilet on the ground floor of each house. Each house has a designated staff member rota’d during the day, and at night, and there is an additional waking night staff based in one house to meet the night-time needs of its residents. Public transport is available close-by. The service obtained the Investors In People award in 2005. The current fees at the time of inspection were £1230.99 per week. DS0000011211.V305721.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit from 12.30pm until 7.00pm on 14th September 2006. This report also includes reference to documents completed and supplied by the home, and those examined during the course of the site visit. The report also draws from very limited conversations with service users, most of whom were unable to communicate verbally, the manager and one staff member on duty at the unit, and from six returned service user questionnaires, which were completed by residents’ keyworkers in consultation with residents. The inspector also toured the premises and observed parts of residents’ lunch and teatime meals. Indications from service users were that they enjoyed living in the home and were relaxed and happy around the staff. It was evident that they were expected to be involved in the day-to-day operation of the home in terms of household routines, and making decisions for themselves with support and prompting by staff. What the service does well: The unit has detailed care plans and maintains detailed records of the daily achievements of residents. The progress of individuals is reviewed regularly. Residents are encouraged to achieve regular goals and develop their self-care skills. Staff are good at verbally prompting and encouraging residents. Care is individualised and staff demonstrate a good knowledge of the nonverbal communication methods of each resident. Residents are able to access a range of individual and group activities, supported by staff, and make use of community resources. Meals are provided with regard to the choices of residents, with staff maintaining an overview on balancing the diet and healthy eating. The specific needs of one resident are met by liquidising his meals. The residents are involved in shopping for and preparing meals. They can choose to eat together as one group or separately within each house. Healthcare records are individualised to address the needs of each resident, and there are detailed records of support from external healthcare professionals. The unit accesses specialist help as required. DS0000011211.V305721.R01.S.doc Version 5.2 Page 6 The staff have all received POVA training and systems are in place to protect residents from abuse. The service provides care within a warm and homely environment which is well maintained and decorated. Residents have the opportunity to spend time with the group or alone if they wish. There is a large garden with a trampoline available to residents. Each resident has their own personalised bedroom. The staff are well trained and competent. Staffing levels meet the current needs of the resident group, and staff demonstrated a good understanding of the non-verbal communication methods of residents. There was evidence of warmth and humour in their interactions. Staff training records are good and good progress is being made with NVQ. Recruitment systems are also appropriate. What has improved since the last inspection? What they could do better: The home will need to devise its own assessment format for future referrals to ensure that all relevant information is available to inform decision making. A Service User Guide in a format more accessible to residents is needed. There is a need to check the limitations on the appropriate use of the “motability” vehicles owned by two of the residents. Serious consideration should be given to obtaining a unit vehicle, to provide transport for other residents. Should a resident develop a pressure area in future, specific records should be maintained to monitor the effectiveness of its treatment. Although medication management is effective, there is a need to record the quantities of medication received as the start of the medication audit trail. DS0000011211.V305721.R01.S.doc Version 5.2 Page 7 The home does not currently have a washing machine with a sluice cycle. Given the age of the resident group and the beginnings of continence management issues, the need for a sluice cycle washing machine must be kept under regular review. The required monthly Regulation 26 monitoring visits, by the provider have not been taking place and no reports of these were filed in the unit. This must be rectified. There is also a need for further development of the quality assurance system and the production of an annual development plan, perhaps by expansion of the existing business plan. Accident records require improvement to ensure that both individualised and collective records are present, and the fire risk assessment will need to be revised to include additional information. The provider/manager will need to provide approved means of restraining fire doors if it is deemed necessary for them to be held open during the daytime. The use of wedges is not acceptable. The manager should ensure that the fire alarm service is carried out regularly and that appropriate certification is available within the unit to evidence this. 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. DS0000011211.V305721.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 DS0000011211.V305721.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care needs of existing residents have been recently re-assessed by their funding authorities and the home meets their current needs. However the home will need its own assessment format in place to ensure that the service can effectively meet the needs of any new prospective resident, in the context of the existing resident group, especially where insufficient information is available from other sources. There is also a need to produce a Service User Guide in a form most accessible to residents, to supplement the Statement of Purpose, which had been recently reviewed. EVIDENCE: The home has a detailed Statement of Purpose, which was reviewed in November 2005. As yet, the home does not have a completed Service User Guide in an accessible format. Some development work has been done, but the images used and the benefits of other media should be carefully considered to best meet the needs of current residents. The advice of speech and language therapists can be helpful in this regard. DS0000011211.V305721.R01.S.doc Version 5.2 Page 10 Within the procedures file there is a generic referral/admissions procedure which refers to residents with mental health needs, for which the home is not registered. This document should be removed to avoid giving the impression that residents with mental health needs can be accommodated. All of the current residents are long-standing, and all were re-assessed by their authorities in 2005 to reassess the funding of their needs. The service meets the needs of the current residents. The unit does not currently have its own preadmission assessment format for prospective residents. A suitable format must be devised ready for future referrals for the remaining vacancies at the home. This is required, where the necessary information is not available from other competent sources, but should be undertaken in all cases to ensure that all relevant information is available to enable an informed decision to be made in the context of the existing resident group. DS0000011211.V305721.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual needs of residents are addressed through detailed care plans and individualised recording of relevant issues and progress. Staff are familiar with the communication methods of the individual residents, and enable and support them to make day-to-day choices/decisions in their lives and to participate in the daily running of the home to their level of ability. Residents are supported to take calculated risks within a risk assessment strategy to maximise their involvement and independence. EVIDENCE: Each resident has a detailed care plan in place, which includes individual goals, and progress is monitored and recorded. There is also evidence of periodic inhouse review of the care plans as well as external review by placing authorities. The staff member interviewed confirmed appropriate involvement in the review and care planning process. DS0000011211.V305721.R01.S.doc Version 5.2 Page 12 Each resident also has a daily care record which includes records of daily achievements around identified goal plans and skills charts to monitor progress. Tracked residents’ records also include regular weight records. The identified goal plans are around maintaining and improving daily living skills and involvement in day-to-day household tasks. These are good records and indicate appropriate progress and encouragement, through the use of lots of verbal prompts. Daily care records are also detailed and cross reference to other records. Individual records include specific formats to address individual’s needs and behaviours and reflect a thorough approach to recording. Residents are encouraged and supported to make day-to-day decisions and to be actively involved in their care. They are involved in purchasing of their clothes and other items, though none would be able to manage their money without support. The choices of individual residents around meals, are recorded on menu copies kept for the record. Individual recording and storage of residents’ funds, are maintained, together with receipts for any expenditure. The current residents have limited verbal communication but staff know them well and are able to establish what an individual wants through various nonverbal techniques, including leading, and the use of pictures and photos. Residents are supported to take calculated risks within a risk assessment system. Individual risk assessments are in place across a range of areas, and are countersigned by the staff to confirm they have been read. This is good practice. Same gender care is the norm, where personal care support is required, and this is usually possible, though none of the residents is known to have an issue where this is not possible. The staff member reported that a resident would be asked if there was a problem before intimate cross-gender care was provided. DS0000011211.V305721.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents take part in an appropriate range of activities both within the unit and in the local community. They utilise local community resources and attend events. Relationships between staff and residents were observed to be positive and family contact is supported where possible. The rights and responsibilities of residents are recognised and supported, and they are actively involved in the day-to-day tasks in the home. They receive a healthy diet and are involved in choosing and shopping for what they want to eat as well as some food preparation. Clarification should be sought regarding the use of “Motability” vehicles. EVIDENCE: The involvement of residents in various activities may be recorded within goal plans or daily notes. Risk assessments are put in place where necessary. Outside the unit, residents visit the local nature reserve for walks and to feed DS0000011211.V305721.R01.S.doc Version 5.2 Page 14 the ducks, attend football sessions via “Sport Reading” and sometimes attend professional matches with staff. Residents were also due to attend the Newbury Show. The home has a good-sized garden, which some use to play football, and there is a trampoline available. The involvement of residents in community activities is recorded within daily notes, as is their contact with relatives. The spiritual needs of residents are addressed, through regular church attendance by four of the group. On the day of inspection, all of the residents went out on their regular bowling trip, and one was taken out later to a Mencap cookery session. Residents also visit a local pub with staff. Two of the residents were able to indicate they enjoyed the activities and outings, and one was happy to show the inspector the photographs of their recent holiday to a holiday camp in Bognor, which he had clearly enjoyed. Some of the residents are taken to join the holiday and outings on a day basis rather than staying away from the home, to address potential anxiety issues. The staffing did not appear to restrict the access of residents to community activities though staffing was usually planned around the regular outings and activities. The unit has three staff who are drivers, and one more is learning to drive. If no driver is available the unit uses taxi tokens to access activities within the community. There was a relaxed and warm relationship between staff and residents and the staff routinely involve residents in conversations, and there were moments of shared humour. Two of the residents have “Motability” vehicles purchased by their funding authorities, but as well as other residents accompanying the vehicle “owners” on trips out in their cars, there are occasions when the cars are used for trips not including the “owner” (or on their behalf), and this may be problematic. The unit should ideally have its own vehicle for transporting residents out in the community. The use of “Motability” vehicles not including, or on behalf of the “owner”, should be checked with the scheme and the purchasing authority. The relationships between residents were mostly positive though it was reported that there could be friction between two of them at times. Family contact varied from weekly, annually, and one resident had no contact from relatives. One visits family regularly supported by staff. The involvement of residents in daily routines is well documented as part of goal plans and other records. There is a positive expectation of involvement and the development of new skills. DS0000011211.V305721.R01.S.doc Version 5.2 Page 15 Meals are produced in consultation with the residents and those consumed are recorded on the menu sheets. Residents are involved in shopping for the meals as well as some food preparation. The specialist needs of one resident are met through liquidising their meals to reduce the risk of choking. The observed meals were relaxed and taken together as one group, along with staff. The conversations were led by staff, but involved the residents. Choices were offered to them along the way. The staff try to include healthy elements in the diet chosen by residents in order to balance some of the less healthy choices. Fresh fruit was readily available on the dining table. DS0000011211.V305721.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive individualised support with personal care, much of which is through verbal prompting, to encourage developments in self-care ability. Their physical and health needs are met effectively and health-care records are generally well maintained. Should pressure areas develop in the future, specific monitoring records to demonstrate the effectiveness of treatment need to be established. Medication is managed on behalf of residents, as none is able to manage their own medication. Staff receive appropriate training and recording systems are appropriate apart from the need to record the quantities of medication coming into the home. EVIDENCE: Support is offered on an individualised basis, and staff have identified the preferences of residents wherever possible. Dignity and privacy are provided for, and the norm is for same-gender personal care support, though this was not felt to be an issue for the current residents. DS0000011211.V305721.R01.S.doc Version 5.2 Page 17 Plans have already been made to replace the step-up shower within one resident’s en suite bathroom, with a walk-in type and an OT assessment had already taken place. Much of the personal support offered is via verbal prompts to encourage selfcare wherever possible. Sometimes it is necessary to encourage individuals to make choices from pre-selected appropriate items, perhaps in terms of the weather or to avoid excessive changes of clothes. Records of individual healthcare were in place on an individualised basis, including weight records, toileting and continence records, behavioural records, records of seizures, falls summaries and detailed records of the level of achievement of designated individual goals in terms of self-care etc. The records include appropriate cross-references to other documents. There were also individual logs of contact with external medical practitioners, colour coded for ease of tracking, together with summary sheets. This is a good system. One resident who has a terminal illness, is receiving appropriate care and has the support of a McMillan nurse. Guidelines in the event of seizures, and rectal diazepam guidelines are in place for the resident who has epilepsy. Staff have received training in these areas as well. One resident had a small pressure area which had responded well to treatment with the previous support of the district nurse. Progress with the care and treatment of this pressure area should ideally have been the subject of a specific record, but this had instead been recorded within daily notes. It is good practice to maintain detailed records of any pressure areas and in future it is recommended that a specific record be maintained. Best practice would include the use of periodic photos of the area to supplement sketches, to record its response to treatment. Medication management was effective, and the records included a photograph of each resident. However, although the incoming medication is being checked, the quantities are not being recorded. This should be done as it provides the start of the medication audit trail. A comprehensive training course on medication management, had been booked via a local college, for four staff. DS0000011211.V305721.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have limited verbal communication, but would be able to express their concern to the staff, who are familiar with their individual non-verbal communication techniques. Observed relationships between staff and residents were warm and relaxed. Residents are protected from abuse and neglect by a staff team who have all received POVA training, and appropriate financial procedures. EVIDENCE: The home has a complaints procedure and log in place, though there are no recorded complaints since 2001, so it was not possible to examine the process in action. There was a second copy of an old complaints procedure in the file, which is not relevant and should be removed to avoid any possible confusion. The residents would be able to express their unhappiness about anything concerning them, to the staff, who are familiar with their individual non-verbal means of communication. The limited verbal feedback available from residents indicated they were happy with their care and body language indicated positive relationships between residents and staff. The lack of the required monthly Regulation 26 visits could remove one avenue by which residents might express a concern to the proprietor, if they are not routinely asked about their satisfaction within this process. Although it is understood the proprietor visits the unit informally on a regular basis, the DS0000011211.V305721.R01.S.doc Version 5.2 Page 19 absence of Regulation 26 reports makes it impossible to examine this consultation in action. (Requirement made later under standard 43) All the staff have received training on the protection of vulnerable adults. The individual storage of residents’ funds, and the individual recording/ receipting of expenditure, help to protect residents’ monies. As noted earlier, however, the conditions of use around the two residents’ “motability” vehicles should be clarified. (Recommendation made earlier under Standard 13). DS0000011211.V305721.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely, comfortable and safe environment, which is wellmaintained and pleasantly decorated. The home is clean and hygienic, though the need for a sluice-cycle washing machine should be kept under review. EVIDENCE: The home consists of two adjacent houses both of which provide full catering and bathing facilities, communal areas and bedrooms. Residents have the option of spending time in the house where they live, or communally. This extends to mealtimes, which also may be individual or communal. Each resident has a single bedroom which offers individual privacy. The bedrooms are individualised and pleasantly decorated, to the preferences of their occupant. Three of the current bedrooms have en suite facilities. One further designated bedroom, not currently let, also has an en-suite. This room is currently used as the manager’s office. If it is to be let in the future, consideration will need to be given to providing a suitable alternative office. DS0000011211.V305721.R01.S.doc Version 5.2 Page 21 In one bedroom, an OT assessment has taken place with regard to replacing the existing step-up shower, with a walk in shower to address the changing needs of the resident. Aside from this, the en-suite and communal bathing facilities meet the current needs of residents, though this is an aging group and further adaptations are likely to become necessary in due course. The two houses have a good-sized combined garden with a trampoline provided. Most of the garden is turned over to lawn. The home was clean and odour free. The laundry has a washing machine without a sluice cycle, though the current need for this was reported to be occasional. Given the age of the group, it is likely that a sluice-cycle machine will be needed in the future, and the situation should be kept under review. DS0000011211.V305721.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent staff who are suitably trained and communicate effectively with them. The home provides a good range of training to staff. The home has an appropriate recruitment policy in place to protect vulnerable residents. EVIDENCE: The staff observed had a relaxed and easy manner with residents and involved them in conversations when they were present. Though very little verbal feedback was obtainable it was evident that residents related well to the staff on duty, and there was warmth and humour in their interactions. Staff demonstrated a good awareness of the non-verbal communication methods of residents and these were also recorded. One of the team has attended a “training the trainer “ course and is an accredited trainer on fire safety for the team. A detailed medication training course has been booked for four staff, through a local college. DS0000011211.V305721.R01.S.doc Version 5.2 Page 23 The manager maintains good training records, with a log of training attended, and a file of training certificates for all staff. Recent training has included supervision, moving and handling, valuing people and person-centred planning, death and bereavement, epilepsy and rectal diazepam, food hygiene, LDAF mentoring, 1st aid appointed person, dementia, POVA, health and safety and 1st aid. Induction records are kept in writing on a typed format. Although signatures of supervisor and supervisee are present, these records are not dated. It is good practice to have induction records dated. Three staff have commenced their LDAF induction/foundation and three are doing NVQ level 2, with one undertaking the NVQ assessor units. The manager has NVQ level 4 and Registered Manager’s Award, one staff who is nursetrained has completed the assessor training, two staff have completed NVQ level 2, one of whom has undertaken level 3. Staff meetings are held monthly and the agenda is open to all staff. Supervision is available between monthly and two-monthly and there was a record of the booked dates on the office wall. The staff member on duty confirmed the ready availability of training for staff. The usual staffing is three staff throughout the day with a sleep-in staff in each house and a waking night in one house. This was said to meet the current needs of residents. Staff recruitment records were sampled and found to be appropriately rigorous, with the required evidence of the process retained on personnel files. It was noted that the home has attained “Investors In People” status in November 2005. DS0000011211.V305721.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed effectively on a day-to-day basis, by the manager. The views of residents are being sought, as part of a quality assurance system. However, the system should be further expanded to include the seeking of views from external healthcare professionals, and the production of a summary report to those who took part. The current business plan could be expanded to meet the need for an annual development plan for the home. The provider must ensure that monthly Regulation 26 visits take place and that the resulting reports are copied to the manager for filing in the unit. There is also room for improvements in the systematic filing of accident records. The home’s fire risk assessment required additional input, and the provision of appropriate fire-door holdbacks must be considered if internal fire doors need to be held open during the day to facilitate residents’ ease of movement about the house. Clarification is required with regard to the fire alarm servicing, and possibly a further visit will be necessary. DS0000011211.V305721.R01.S.doc Version 5.2 Page 25 EVIDENCE: The home is run by an experienced and competent manger, who has attained NVQ level 4 and the Registered manager’s Award. The manager also maintains her current knowledge by continuing to attend training. The provider has not been undertaking Regulation 26 monitoring visits, per se, and the reports required by Regulation 26 have not been produced or provided to the manager to be filed in the home. The provider must ensure that monthly Regulation 26 visits take place and that a report of the findings is produced for each visit and provided to the manager to be filed in the unit. Although the manager has undertaken some quality assurance surveys, no report has been produced summarising the findings. A report should be produced following each annual cycle of quality assurance, summarising the findings and detailing any action taken in response to any identified concerns. At the point of inspection, quality assurance questionnaires had reportedly been completed with and on behalf of three of the residents, by their keyworkers, and this will be extended to include the remaining residents. The manager also plans to send questionnaires to next of kin. It would usually be recommended that the views of care managers also be sought, but it was reported that none of the current residents has an allocated care manager. It is recommended that the views of any external health professionals with whom the home has regular contact, are also sought as part of the QA system. Although there is also no annual development plan produced for the home, the business plan which is in place, goes part way towards fulfilling this role, and could be expanded to meet the requirement, rather than producing a separate document. The home maintains accident records for any accidents to residents, which are sufficiently detailed, though some are on an older, small format. It is suggested that the new tear-off pad is used for residents of either house as the two houses are part of the same registration. Copies of completed accident forms must be filed on individual residents’ case record files as part of their care history; as well as being held collectively to enable efficient monitoring of accidents and the identification of any trends or patterns of concern. The home has a collective fire risk assessment in place, dated July 2006, which includes individual fire evacuation risk assessments and plans but no reference DS0000011211.V305721.R01.S.doc Version 5.2 Page 26 is made to specifics relating to the premises, such as access problems and the use of wedges to facilitate mobility about the home. The fire risk assessment should be revised to include all relevant aspects. The use of wedges on fire doors is unsafe as it prevents the door closing via its integral self-closer in the event of fire. If any door holdback device is used it should be risk assessed in writing. It is preferable to use approved devices that are integrated into the fire alarm, to trigger door closure on the sounding of the alarm. The advice of the fire authority should be sought. Examination of a sample of the required health and safety-related certification and servicing indicated that the majority was up-to-date and certification was in place. In the case of the fire alarm, the most recent certificate was for over a year prior to the inspection (May 2005). This is not satisfactory and the manager should pursue details of the most recent service and pursue a further visit if one has not taken place within the last year. DS0000011211.V305721.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 2 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 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 2 X X 2 X DS0000011211.V305721.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 Standard YA1 YA2 YA20 Regulation 5 14 13(2) Requirement The manager must produce a Service User Guide in a format most suited to residents’ needs. The manager must devise an in house pre-admission assessment format for prospective residents. The manager must instigate a system for recording the quantities of medication coming into the home. The provider must ensure that monthly Regulation 26 visits take place and that the resulting reports are copied to the manager and filed in the unit. The manager must ensure that both individualised and collective records of accidents to residents are maintained within the home. The manager must ensure that the fire risk assessment for the unit addresses all relevant areas. The manager must ensure that any fire door restraints are approved by the fire authority, and enable the fire door to close immediately via its self-closer in the event the fire alarm sounds. DS0000011211.V305721.R01.S.doc Timescale for action 14/12/06 14/12/06 14/10/06 4 YA39 26 14/10/06 5 YA42 6 6 YA42 YA42 17(2) Sched. 4.12(a) 17(1)(a) Sched. 3.3(j) 23(4) 23(4) 14/10/06 14/11/06 14/10/06 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 YA13 Good Practice Recommendations The manager should confirm the conditions under which “Motability” vehicles may be used by residents other than the designated owner, and consideration should be given to the unit obtaining its own designated vehicle. Appropriate records should be maintained of any future pressure area, to demonstrate the progress of treatment. The manager/provider should keep the need for a sluicecycle washing machine, under regular review. The manager/provider should consider broadening the quality assurance system to include the seeking of views from any regularly involved healthcare professionals and should produce a summary report of findings, which is made available to those who took part. The manager/provider should consider the expansion of the business plan to fulfil the need for an annual development plan for the home. The manager should establish the date of the most recent fire alarm service, and arrange a service if this was not within the past twelve months. 2 3 4 YA19 YA30 YA39 5 6 YA39 YA42 DS0000011211.V305721.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South, Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000011211.V305721.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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