Inspection on 17/05/07 for Katherine House

This inspection was carried out on 17th May 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Katherine House 10/03/09

Katherine House 02/09/08

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Katherine House 91-93 Sutton Road Erdington Birmingham West Midlands B23 5XA Lead Inspector Donna Ahern Unannounced Inspection 17th & 21st May 2007 11:45 Katherine House DS0000068481.V340392.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 Katherine House DS0000068481.V340392.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. Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Katherine House Address 91-93 Sutton Road Erdington Birmingham West Midlands B23 5XA 07834977180 Not available Not available 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) Pharus Care Limited Mrs Julie Quigley Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Care home only (PC) Learning Disability (L/D) 9 Date of last inspection New Registration Brief Description of the Service: Katherine House is a large detached house and provides twenty–four hour care and support for nine people with Learning Disabilities, Autism and Challenging Behaviour. There were six people living at the Home at the time of the fieldwork visit. The home is situated on Sutton Road in Erdington. It is close to the centre of Erdington where there are a variety of shops, restaurants and leisure facilities. There are eight single bedrooms, each one with an en-suite bathroom with either a bath or shower. One of the bedrooms in on the ground floor and accessible to a person with limited mobility. All other bedrooms are on the first floor. On the second floor there is a semi independent flat, with separate lounge and bathroom. There are two large lounges on the ground floor a large dining room and a domestic kitchen and a separate laundry. The office and staff sleep-in facilities are located on the second floor. To the rear of the Home is a large garden with lawned area and patio and to the front of the Home there is off street parking. This is the Homes first inspection report. Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one long day returning on a second afternoon a few days later to complete the fieldwork. The inspector met all six people living at the Home, spent time observing support and interactions from staff, had a tour of the premises including peoples bedrooms, looked at care records and health care records and medication management. Health and safety records and staffing records were also assessed. All information looked at was used to determine whether peoples varied needs are being effectively met. The manager completed an AQAA (annual quality assurance assessment), which tells CSCI about how well the Home is performing and achieving outcomes for the people who live in the Home. It also provides some factual information about the Home. Information from the AQAA was used to help inform the inspection process. The inspector met with two relatives during the fieldwork and a telephone discussion took place with a professional and a completed survey was received from another professional. All comments received were entirely positive. What the service does well: What has improved since the last inspection? This is the Homes first Inspection. Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 6 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. Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 7 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 Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s):1, 2, 3 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective peoples needs are assessed prior to admission thus ensuring the Home can meet their assessed needs. Some further information must be added to the Service User Guide so that prospective people and their relatives have the information to enable them to make an informed choice about whether or not they choose to live in the Home. EVIDENCE: The Home is registered for nine people with learning disabilities, autism and challenging behaviour. There were six people living at the Home and induction visits were taking place for three more people. It is anticipated that the Home will be at full occupancy by August 2007. During the fieldwork a prospective person was visiting with support from staff from their current home, which is outside of the Birmingham area. The person was being supported to meet their peers and the staff team and familiarize themselves with the Home. Staff took photographs of the Home so that these could be used to assist the person through the transition process. Overnight visits had been scheduled and staff from the person current Home will also Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 9 stay overnight and work alongside staff at Katherine House so that knowledge and skills in supporting the person can be passed over in a consistent way for the benefit of the person. There is a detailed pre-admission assessment and admission protocol in place which if followed would ensure that a thorough assessment and transition plan would take place ensuring a consistent approach for prospective service users. Pre-admissions assessments were looked at for three people; the registered manager and the operations director had completed these. One of the admissions was an emergency referral therefore no introductory visits took place prior to admission. There have been some difficulties with supporting people in what are the very early stages of a new service. The manager agreed to review some of the monitoring procedures to maximise people’s safety and well-being. These matters are referred to in more detail under the concerns and complaint section of this report. Staff spoken with during the inspection spoke positively about training they have completed and the preparation that had been done prior to new people being admitted to the Home so that they have the skills and knowledge to meet people assessed needs. The statement of purpose describes the aims, objectives and facilities of the Home. The copy forwarded to CSCI as part of the Homes registration process states that no emergency admissions would take place this will need to be up dated to reflect current practice in the Home. An amended copy of the statement of purpose detailing any changes should be sent to CSCI. The service user guide must be further developed so that it contains details of the range of fees and includes details of additional charges, what they are and how they will be made. The manager said there are plans in place to develop this document further so that it is more accessible to the people who live at Katherine House. Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 10 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 adequate. This judgement has been made using available evidence including a visit to this service. Good progress has been made on implementing a comprehensive care plan for each person. This should ensure that people receive support from staff in a consistent way that meets their individual needs. Risk assessments should be further developed to ensure that the risks people face is well managed. EVIDENCE: People have very complex needs and it is essential that comprehensive plans are in place for staff to follow so they can meet people assessed needs. There was a detailed care plan in place for each person and three were looked at in some detail. These were seen to contain personal details; “Some great things about me” which was information about peoples preferred lifestyle and experience in making choices. Family history details are documented including how to contact people and “Things I like” “Things I don’t Like”, Health and Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 11 medical history, communication needs, sexuality and daily routines. There is a plan of care and support plan detailing how personal care needs will be met. Monthly evaluation sheets are contained throughout the different sections of the individual plan so regular reviews are made and any changes in needs identified. A copy of Social Services care plan was also on people’s file. People spoken to during the inspection said “I see my care plan staff talk to me about it”. There was evidence that some people had signed their care plan and on one of the care plans looked at there was a record of “talk time” where staff had spoken to the person on a one-to one about their care needs and had recorded what the person wants. There were some pictures used within the care plan so that it is more meaningful for the person. Considering the relatively short period that many of the people have lived in the Home good progress has been made on developing peoples care plans. The manager recognises that some further development of these is required in response to changes in peoples needs as they become more settled in their new Home. The manager was aware of the need to ensure that people living in the Home should be central to their care plan and how it is developed. A number of risk assessment were in place and some of these were looked at. Again it is positive that these are kept under review with monthly evaluation sheets. However, these need to make specific comments about the control factors in place and if they are working. For instance a person is being supported to access the community and a local park there are risk assessments documented about potential triggers and difficulties that they may encounter. However, when evaluating the risk assessments there is no mention of the control factors in place. The reported practice from staff is that the person has made good progress and is being supported daily to go out into the community, this should be reflected so that a full audit trail of peoples needs can be made and risk assessments can then be developed to further enhance opportunities for people. Meetings with the people who live in the Home are held regularly and minutes were available to read. It is recommended that the minutes are developed to include what action has been taken on issues raised as evidence that people have been listened to and consulted on a regular basis. During the fieldwork staff were observed encouraging people to make choices about day-to-day matters, such as what they wanted to do on that day, if they wanted to go out, where they wanted to spend some time such as their own room or the communal areas of the Home. People’s ability to exercise choice and to make informed decisions is variable, according to their degree of learning disability. Staff spoken with were able to describe how people’s views were sought and choices were offered to people. Specialist communication training has been arranged for the manager and team leaders who will then cascade this training to the staff team. They will support staff in the implementation of developing effective communication Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 12 systems so that people living in the home are supported with their communication to make choices and decisions about their life. Katherine House DS0000068481.V340392.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. This judgement has been made using available evidence including a visit to this service. Arrangements are in place so that people who live at the home experience a meaningful lifestyle. People are supported to maintain contact with relatives and people important to them so they have the opportunity for personal relationships. EVIDENCE: During the fieldwork the inspector met with two relatives who made the following comments. “ We are very happy with the home” “ Staff make me feel very welcome, I Sit in the lounge with everyone and one of the other people living in the Home will make me a drink”. “Staff are very kind, I have no concerns I feel like I am just visiting a friend at their house”. Discussions with people living in the Home, staff and service users relatives indicated that people receive good support to maintain contact with relatives and the Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 14 importance of personal relationships is recognised. People’s family contact details are recorded on their care plan. There are opportunities provided for people to maintain and develop new skills, people were observed undertaking some basic domestic tasks such as taking used crockery back to the kitchen, cleaning the dining table and helping with drink making. Conversations with people, staff and reading of care plans indicated that people are really encouraged and enabled to maximize their potential in every day living skills so they can live as independent as life as possible. They are encouraged to vacuum their own bedrooms change their beds, bring down clothes to be laundered. The degree that people are involved is variable due their individual needs but there is an ethos within the Home that this will be encouraged. One of the people who helps out in the Home by doing a range of household tasks is paid for the work they do, which is an indication that peoples contributions are valued and a recognition of the importance of paid work. People are involved in a range of household activities and supported to access facilities in the community. This is gradually being developed as staff get to know the person and help them to try out new activities. Each person has an activity folder which have been produced in an easy read and picture format so that they are meaningful to the individual and include activities for each day such as swimming, out for drive to the park, shopping, puzzles and listening to music, bingo, household tasks and art class. The Home has a Galaxy people carrier and will be getting another Galaxy and a car, which will provide a good choice of transport to support people accessing the community. Some people said they also use public transport. The manager agreed to formalise the arrangements for people making contributions to the transport, this is raised under the complaints and concerns section of the report. People were seen to freely access all areas of the Home including their own rooms, the garden and the good choice of communal areas. The kitchen is locked at 9.30 pm based on a risk assessment. This was discussed with the manager during the fieldwork who agreed to develop the risk assessment to include restriction issues. Any restrictions in place to protect one person should have a minimum impact on the other people living in the Home. The risk assessment must be kept under review. The manager said drinks and snacks are available after this time waking night staff would support people to access these. The evening meal was observed and the food looked really nice it was a chicken and pasta dish. People can eat together or on their own later when it is quieter. It was positive that staff sat with people during the evening meal making it a sociable time. People’s specific needs during mealtimes was documented on their care plan and followed through in practice. Menus seen Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 15 offered a choice and indicated that healthy eating is promoted and cultural and dietary needs are catered for. The menu folder is under development and staff said there are plans to produce menu choice in a picture format to enhance opportunities for people with limited verbal communication in making choices about what they want to eat. Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s):18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People receive personal support in the way they prefer and require and their health needs are met. The management of medication must be reviewed so that the procedures protects people and ensures their well being. EVIDENCE: Care plans looked at had details about how personal care needs should be met and include people’s preference in meeting needs and how independence should be maintained and promoted. People living at the Home have very complex needs and there is a balance of male and female and there will be people from different cultural backgrounds living at the Home. The staff team has a really good mix including gender, culture, age and experience this ensures that people are supported by a diverse staff team reflective of the wider community. There is always a team leader on shift who can lead and direct care for the benefit of people. Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 17 People met with had been supported by staff to look well groomed and were dressed appropriately to their age, culture, gender and the weather. All bedrooms have ensuite facilities with either a bath or shower ensuring that personal care is delivered in a way that promotes people’s privacy and dignity. There is a separate bathroom designed for therapeutic bathing. None of the present people require lifting aids for bathing. Health Action Plans have been implemented these are what the Government paper, ‘Valuing People’ recommended that each person with a learning disability should have. This is to ensure individuals receive all the care they need to stay healthy. The Manager said that although Health Action Plans are in place, these are to be developed so they are more detailed in content. Staff training on Health Action Plans is scheduled and new plans will be implemented ensuring a comprehensive system is in place for each person. Staff have received training on epilepsy and epilepsy protocols were in place following guidance from the community nurse. Referrals have been made to other specialist services where it is felt this is needed. The systems for the safe handling and administration of medication were satisfactory managed. Medication storage is currently in a medical trolley stored in a locked room off the dining room. It was advised that medication storage is reviewed and consideration given to individual locked cupboards in peoples rooms. This would provide a more individual approach and could also be a move towards self-medication for some people, based on individual risk assessments. Medication administration records sampled had one gap where medication had been given but not signed for. There are robust signing procedures in place so these must be reviewed to identify why the shortfalls occurred. Staff have completed satisfactory medication training and The Homes practice is that only team leaders administer medication. Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s):22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are not fully protected by the Homes procedure, which has the potential to place people at risk of harm. EVIDENCE: This is a relatively new Home and the manager stated that no complaints have been made since the Home was registered (November 2006). CSCI received one complaint in January 2007 regarding recruitment practice and this was sent to the provider to investigate. Complaints must be logged with details of how they were investigated and their outcome to ensure that the procedures are followed and concerns are dealt with. The multi-agency guidelines for the protection of vulnerable people were available and the Home has its own vulnerable person procedure. When talking with staff there was some concern about their understanding of the reporting procedures. Staff said that incidents would be reported to the manager or owner and some said the police. Staff didn’t seem clear about Social Services role as the lead agency in the reporting of concerns, or how they would access this information. It was agreed with the manager that contact details would be available in a flowchart format for staff to follow. This will include the need to inform the local social services office as well as peoples own placing authority and CSCI in the event of an incident occurring. The manager agreed some refresher training would be done with staff team to reinforce their responsibilities so they know who and what to report. Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 19 When reading peoples care plans and cross-referencing incidents to the accident book, incident record and regulation 37 records, there were significant shortfalls. Incidents had not been logged as a regulation 37 and reported to CSCI as required. This included incidents of people in the Home being hit by other service users. However, minutes of people’s reviews indicated that concerns had been discussed formally with peoples placing authority. The manager agreed to do a full audit of accidents and incidents and ensure systems are reviewed so that incidents are reported as required. The manager must also ensure that social services and peoples placing authority are informed of any incidents when they occur because they are the lead agency. If Social services require any further information or for further investigation to take place they will then be in a position to instigate this. Whilst acknowledging that this Home does support people who have complex and challenging needs and there is the potential for incidents to occur, robust systems must be in place so that incidents are properly monitored so that people’s safety and welfare is promoted and protected. As previously highlighted the Home has its own transport so that people can be supported to access a variety of facilities in the community. Some people are making contributions to the vehicle running costs. An equitable system must be established which details what the charges are and how these will be made. This information must be then detailed in the service user guide. Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s):24, 25 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, comfortable, homely and well maintained home. EVIDENCE: The physical standards of the Home have been commissioned to a high standard. Expert advice was sought when planning the décor so it is low stimulus. There is a lovely large, open and welcoming entrance hall. There are nine single bedrooms with ensuite bathrooms. The communal space is very good with two large lounges for people to relax in and a large dining room. The rooms have been made very comfortable and relaxing with a good use of pictures and soft furnishings so that it is comfortable and relaxing for people. People spoken with said “I love my bedroom it is really comfortable but I also like spending time downstairs with everyone” another person said “I like my room I have got all my own things in here and I am going to get some more storage”. Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 21 The manager said bedrooms where painted a neutral colour and some people are now starting to plan the colour they would like their own room painted. A room on the ground floor had been identified as a sensory room but not yet fitted out. The manager said the use of this room would be reviewed so that it best meets the needs of people and it may be developed into an activity room. There is a large garden to the rear of the House and there is some outdoor seating and a barbecue. The kitchen is well equipped and domestic in scale the supervision of this area is slightly hindered by the storage of the fridge and freezer, if possible some thought should be given to how this could be improved so that people can be safely supported and supervised in the kitchen. There were some minor repairs and some replacing of furniture, which the manager confirmed were in hand. Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s)32, 33, 34, 35 and 36: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recruitment procedures must be improved so that people are protected by robust procedures. Staffing level must be reviewed at night so that there is adequate staff to support peoples assessed needs. EVIDENCE: A high level of staff support is required to meet peoples assessed needs. The rota seen indicated that there is currently five staff on duty across the day. The manager said that this is under review and as occupancy levels rise staffing levels will be increased. Many of the current people require one to one support and some require two to one support to safely access the community. At night there is currently one staff member on duty and one staff member on call doing a sleep in shift. In light of the complex needs of people and the layout of the Home over two floors night-time staffing levels should be reviewed and consideration must be given to having two waking night staff. Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 23 It is advised that consideration is given to the employment of a cook as at present support staff are doing all meals for a large group of people and this is taking staff away from their role of supporting people. The Staff files of the two recently appointed staff were looked at. Checks of the person’s suitability to work in the home had been made; including satisfactory Criminal Records Bureau checks, completed application form and proof of identification. However some shortfalls were found including no copy of staff’s terms and conditions of employment were on file, no profiles detailing start dates of employment, one person started employment with only one reference on file, no recent photograph on staff files although these had been taken on the digital camera and one persons application form lacked details of dates of employment. The recruitment procedures must be reviewed to ensure robust systems are in place to protect people. Staff spoken with had a good awareness of individual needs and how to meet them they felt that they had been given good information about how best to support people, they spoke with a high regard and respect for the individuals living at Katherine House. Staff spoken with were positive about the training opportunities, they said they get the training they need to meet peoples needs. The training matrix required some updating by the manager to reflect the training that has taken place. All staff are doing the Ldaf training (Learning disability award framework) and specific training has been provided on epilepsy, autism, medication, crisis prevention intervention training, fire safety, food hygiene and infection control. Formal supervision is regular, and regular staff and managers meetings are held which ensures staff are supported and that there are established systems in place for the sharing of information and to monitor staff performance. Katherine House DS0000068481.V340392.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, 40, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements must be made to the implementation of the Homes systems so that people’s safety and well-being is protected. EVIDENCE: The registered manager was previously registered as a manager and has a number of years experience working with people with learning disability with associated autism and challenging behaviour. She has NVQ level 2, NVQ level 4 in care and The registered Managers Award. She also has an Advanced Certificate in Special Education-Autism and a Certificate in Profound and Multiple Learning Disability. The manager works “hands on” and said that in the early stages of a new Home she feels it is imperative that she works alongside staff to support and Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 25 monitor practice. This was evident throughout the fieldwork. The manager presented as open and welcomed the inspection process and responded well to feedback and a commitment to address any shortfalls identified. Comments received from people living in the Home, staff and relatives were entirely positive about the management style on the Home. Improvements must be made to the systems in place for the monitoring and reporting of significant incidents so that people’s well-being and safety is protected. Improvements are also required to the recruitment process and the information held on staff so that the Home can demonstrate that robust systems are in place to protect people. The building is commissioned and maintained to a high standard. Safety checks were looked at including hot water temperature checks, general risk assessments, health and safety audits and Fire records which ensure regular testing and service of equipment take place as required, to protect the safety and well being of people living at the Home. The operations director has completed regulation 26 which are detailed and had evidence of discussions with people living in the home thus ensuring that the provider takes responsibility for monitoring the Home. However, copies of regulation 26 reports were not available for March and April 2007. The operations director acknowledged the shortfall and has appointed someone to do these visits in the future and to support the manager in the development of the Home. The manager has developed surveys, which have been distributed to professionals and relatives asking for feedback, suggestions comments or concerns about the Home. One had been completed by a professional and returned to the Inspector and stated, “I have been impressed by the high level of professionalism and quality of care provided by all staff members. I have witnessed real choice and freedom of expression being exercised”. It was advised that outcomes of peoples meetings are developed so that these link into the quality assurance system indicating that peoples views are sought and that they are listened to. Katherine House DS0000068481.V340392.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 2 2 3 3 3 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 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 2 X 3 2 Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 27 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 YA22 Regulation 22 Requirement Timescale for action 15/06/07 2 YA23 13(6) 3 YA34 Sch2 7,9,19 4 YA43 26 Complaints must be logged with details of how they were investigated and their outcome to ensure that the procedures are followed and concerns are dealt with. There must be robust systems in 15/06/07 place for the reporting, recording and monitoring of incident and accidents so that people’s safety and welfare is promoted and protected. The recruitment procedures 15/06/07 must be reviewed to ensure robust systems are in place to protect people. Shortfalls found include no copy of staff’s terms and conditions of employment no start dates of employment, one person started employment with only one reference on file, no recent photograph of staff and lack of dates of employment. The owner must make regulation 30/06/07 26 visits monthly to ensure the home is being managed appropriately. Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 8 9 Refer to Standard YA1 YA1 YA6 YA9 YA16 YA19 YA20 YA20 YA23 Good Practice Recommendations The statement of purpose should be amended to include emergency admission procedure. The service user guide should contain details of the range of fees and additional charges. Care plans should continue to be developed so that all people have a comprehensive care plan. The control factors in place should be fully reviewed on risk assessments to ensure that they are still appropriate. The risk assessments for restrictions on the kitchen must be developed and kept under review. Health action plans should be further developed to ensure that a comprehensive and user-friendly plan is in place. It was advised that medication storage is reviewed so that a system is established that is less rigid and more personable to the individual. There must be robust system in place for the signing of medication records to ensure peoples safety and so that procedures are followed. Contact details of other agencies (Social services etc) and refresher training for staff on vulnerable adult issues should take place so that staff know what to do should an incident occur in the Home. A fair system for the charging of people for the use of transport should be established and shared with relent parties. Policies and procedures must be fully implemented so that people are not put at risk. 10 11 YA23 YA40 Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Local Office 1st Floor Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ 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 Katherine House DS0000068481.V340392.R01.S.doc Version 5.2 Page 30 - 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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