Inspection on 09/05/06 for Life Works Community Ltd

This inspection was carried out on 9th May 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Life Works Community Ltd 09/07/07

Life Works Community Ltd 26/04/05

Life Works Community Ltd 11/08/04

Life Works Community Ltd 23/06/04

Similar services:

Prinsted

Elizabeth House

Kenward House

Boons Park

Winthrop Hall

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

CARE HOME ADULTS 18-65 Life Works Community Ltd The Grange High Street Old Woking Surrey GU22 8LB Lead Inspector Kerry Fell Announced Inspection 9th May 2006 09:30 Life Works Community Ltd DS0000059060.V295742.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 Life Works Community Ltd DS0000059060.V295742.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. Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Life Works Community Ltd Address The Grange High Street Old Woking Surrey GU22 8LB 01753 869777 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) Life Works Community Ltd Barnaby Giles Guthrie Care Home 24 Category(ies) of Past or present alcohol dependence (24), Past or registration, with number present drug dependence (24), Mental disorder, of places excluding learning disability or dementia (24) Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the twenty-four (24) service users, up to four (4) may be accommodated for a de-toxification programme, which requires nursing intervention. 11th August 2005 Date of last inspection Brief Description of the Service: Life Works Community Ltd is situated in The Grange, a grade ll listed building in the Old Woking area of Surrey. The property is set in two acres of mature gardens. The property consists of 7-shared occupancy bedrooms suitable for meeting the needs of service users with substance addictions, compulsive behaviours, trauma, co-dependency and dual diagnosis (addiction and depression/anxiety). Suitable measures have been taken to ensure service users privacy at all times and CCTV cameras are utilised to monitor the external areas of the property. Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection for the inspection year 2006/2007. The inspection was announced at short notice because an inspector from the Healthcare Commission was also invited to attend the inspection. Therefore the members of staff and the clients were aware that the inspection was going to take place. Meetings were arranged with the clients, the home’s GP, the home’s Clinical Psychiatrist, the Nurse Manager, and the Registered Persons. Members of staff were also meet throughout the inspection. The inspector viewed a range of records including client files, personnel records, policies and procedures, health and safety checks, and complaints logs. The inspector also reviewed the management of medication and staff training. It was evident that the home had undertaken a great deal of work since the last inspection, and this is reflected within the report, however, further improvements have been identified. Although there had been a great deal of change within the staff team in the last twelve months, the home had a relaxed and supportive ethos, and staff were observed to be carrying out their roles confidently during the visit. There had been an ongoing case conference under Surrey’s safeguarding procedures, which was closed in March 2006. Recommendations and requirements made during the 12 months that this case conference was ongoing have subsequently been met by the home. Further referrals had been made by the home under Surrey’s safeguarding procedures, none of which had been taken up for investigation by Surrey’s safeguarding team. What the service does well: The home continued to be maintained, decorated and cleaned to a high standard. Clients were complimentary about the support provided by the staff team, especially the access they had to the nursing team and the medical and emotional support offered by the nurses. Food continued to be produced to a high standard and clients commented that they had no complaints about the quality of the food provided to them during their stay. The maintenance manager continued to keep a detailed file of risk assessments for all areas of the home. Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 6 Records continued to be available to evidence that assessments were being completed before admission to the home and that the GP and Clinical Psychiatrist shortly following admission completed assessments. What has improved since the last inspection? What they could do better: Concerns were raised by clients met during the visit about the use of leisure equipment in the multi-purpose room that is also used as a dining area. The Manager must therefore review the times of use and location of the leisure equipment to ensure that this remains appropriate, especially around mealtimes. The nursing team must arrange a number of practice sessions throughout the year. The nursing team must have a policy and procedure with regard to invasive treatments and the management of epileptic seizures. The inspector was disappointed that the review of the complaints procedure had not been completed. The home must review its complaints procedure without further delay, and a copy of the reviewed complaints procedure must be forwarded to the CSCI Surrey Local Office. This is a requirement carried over from the last two inspections. Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 7 Although there were no concerns about how the home was responding to safeguarding concerns. The protection of vulnerable adults policy also needed further reviewed to ensure that it reflected Surrey’s safeguarding procedures. Gaps were again observed in the checks obtained prior to the member of staff commencing work. The registered persons must ensure that staff do not commence work until two written references and a CRB check has been applied for, with in the least a POVA first check having been obtained. Although, service users had a number of opportunities to raise concerns and give feedback, including the monthly visits completed by the registered person, the home still did not have a formal quality assurance programme in place, and one must therefore be introduced. The fire officer made a number of recommendations following their last visit to the home. It was not clear that these had been met by the home, and the home must therefore comply with these recommendations without further delay. The registered persons must additionally report to the CSCI Surrey Local Office what action they have agreed with the fire officer to ensure that this area remains safe for use. 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. Life Works Community Ltd DS0000059060.V295742.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 Life Works Community Ltd DS0000059060.V295742.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 good. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed. Although a statement of purpose and service users guide are available the final draft is still to be completed. EVIDENCE: The original statement of purpose developed by the home had incorporated a client handbook and staff handbook. This document had now been separated out and reviewed and was to be produced in a binder format with dividers for each section. The statement of purpose and service users guide had been reviewed since the last inspection. The Manager had identified a number of additional changes that were to be completed before these documents were to be published as a final draft, this must include a more detailed complaints procedure. Once the final draft has been published a copy must be forwarded to the CSCI Surrey Local Office. At the time of the visit there were only four clients resident at the service. Two client files were sampled, and assessment forms as well as a number of other records and checklists evidenced assessment being completed for clients Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 10 before admission, where possible. The home operates an “assess and admit” arrangement for those clients who are admitted to the service at short notice or as an emergency placement. Assessments additionally included the completion of a psychological history and a nursing intake form. The GP and the Clinical Psychiatrist assess all clients admitted to the service. Life Works Community Ltd DS0000059060.V295742.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. Improvements in the client records, their individual plans, and risk assessments better support and protect the clients and ensure that needs are identified and met. EVIDENCE: The client records had much improved since the last inspection. The home has introduced several new records that form the care plan/treatment plan, and identifies the client’s specific needs, and goals for their stay. Each client has an identified primary counsellor and a link support worker. Although clients stated that they were not aware of what records were being held, and that they had not and did not want to see them, treatment plans had been signed by clients. All staff had completed training in record keeping, and further work with regard to maintaining client records was ongoing. Checklists had been introduced in order to ensure that the required records were completed Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 12 promptly on admission. In addition client records are regularly audited and a record is produced of missing documents and who is responsible. At the time of the visit, no records were found to be missing, and clinical staff met were able to advise the inspector about how all of the records were maintained and how these records were linked together. It was evident that staff had a better understanding of the importance of the records needed, and that these needed to be well maintained. The clinical staff were able to describe and evidence how client treatment plans and goals were kept under review. Clients also countersigned these records as they met their goals and their treatment plans progressed. It was also observed that client records were maintained after the client was no longer resident, as part of ongoing treatment post discharge. The inspector was further advised that clients’ needs were reviewed with the client during one-to-one sessions with their primary counsellor and during group sessions, and that staff discussed progress and ongoing needs during clinical team meetings. Minutes of these meetings were available. The nature of the service provided by Life Works means that decision making is restricted as part of the clients programme of treatment. The clients met felt that this was appropriate, and stated that they had been advised about this prior to admission. The clients also stated that they understood why this was enforced. Discussions with clients and staff during the visit evidenced that clients’ concerns and choices were listened to during the weekly client meetings, and during group and one-to-one sessions. Examples were given about how client’s requests had been acted upon, although the clients felt that this was not always as promptly as they would like. However the Manager did confirm that clients’ requests were always noted and where possible acted upon promptly. Clients were also asked their views when they leave via an exit interview. At the time of the visit the comments were not being collated as part of formal quality assurance. Although it was evident, for example from the monthly visit reports, that client comments were being used to improve the service. The registered persons would be strongly advised to quality audit comments made during client exit interviews, and publish the outcomes and representative comments in the statement of purpose and service users guide. A new risk assessment format had been developed following the last inspection. The tick chart risk assessment was still being used on admission for generalised risks. Where specific risks were identified these were assessed in more detail on the new format. Risks with regard to one-to-one sessions Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 13 were still being recorded on the Cardex form, however at the time of the visit no specific risks were identified. Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Structured treatment programmes, support the clients and promote contact with relatives and friends are promoted as part of the structured treatment programme. The meals are produced to a high quality and are overseen by a dietician. EVIDENCE: Standards 12, and 13 do not apply to this service because of the short term and specific nature of the treatment provided to the clients. However it is important to note that the inspectors were advised that clients are offered post treatment support from community based 12-step groups, and after care groups organised by the home, and support groups are accessed as part of their treatment whilst at Life Works. Clients talked about the activities and sessions that they undertake during their stay. All of the clients talked about structured leisure activities, however some commented that they wished that they could take more leisure/physical exercise. Concerns were also identified with regard to the leisure equipment Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 15 being used in a multi-purpose room that is also used as a dining area. This was discussed with the Manager during the visit. Whereas it is recognised that it may not always be appropriate for some clients to take part in too many leisure sessions, and that the times for the clients to access the leisure equipment is restricted because of their treatment programmes, the Manager must review the times of use and location of the leisure equipment to ensure that this remains appropriate, especially around mealtimes. Arrangements are made for friends and family to visit as appropriate, on Sundays after the first week of treatment. A family week is arranged as part of the treatment programme. Treatment programmes are arranged around a strict routine. Guidance from the European Association for the Treatment of Addiction states that treatment programmes will require that clients participate fully in all treatment activities, and this is detailed within the statement of purpose/service users guide and within the terms and conditions of the client’s stay. Client’s met during the inspection confirmed that they had been advised about restrictions upon their lives when they were admitted. Client responsibilities and appropriate behaviour and “household” chores are detailed within the service users guide. Clients are asked to sign agreement to these responsibilities at the time of admission. A dietician is employed by the home to oversee the treatment programmes for those clients with eating disorders, and programmes are put in place to ensure that these clients receive a balanced diet, and are supported through mealtimes. One client met during the visit stated that they found their mealtime programmes intimidating at first, and at times over restrictive; however they understood the need for the structured programme. With their permission their comments were passed on to the Manager. Menus observed by the inspector offered a varied meal, and staff monitor meals taken. Other clients commented that they had no complaints about the quality of the food provided to them during their stay. The inspector took lunch during the visit, and was found to be appetising and of a high quality. Lunch was a hot meal of chicken and rice, and salad, soup and fresh fruit was also available. A hot meal is also offered at Dinner with a desert. Sugar and caffeine free drinks were freely available, and snacks were offered in the afternoon and evening. Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 16 Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 17 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. Policies and procedures with regard to personal, physical, emotional and medication safeguard and support the clients. EVIDENCE: Clients staying at Life Works generally do not require personal support. None of the clients met during the visit required specific assistance with their care, however clients were complimentary about the support provided by staff and specifically the emotional and medical support offered by the nursing team. The clients were also complimentary about the “hotel” services provided by the domestic team. Client records clearly identified healthcare and medical support needs. The GP stated that they assessed each client on admission and visit to monitor clients throughout their stay. The home employed a nursing team to oversee the client’s clinical needs during their stay. At the time of the visit no clients had been admitted for detox treatment since before January 2006. Discussions took place during the visit about the level of detox treatment provided by the service. The inspector was advised that assessments were made at admission as to whether a client Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 18 required medical detox intervention, although the staff stated that any intervention would always be at the lowest possible level. The inspector was advised that the home did not undertake any intravenous detox treatment and that in all but one case the clients admitted on a detox programme had been actively involved in the programmed daily sessions from the point of admission. The home had appointed a new nurse manager and additional permanent nursing staff since the last inspection. The Nurse Manager advised the inspector that although the nursing policies and procedures had been reviewed fully by the nursing team, no changes had been made. The Nurse Manager was planning to look at these again to ensure that they remained up to date and relevant to the homes current practice. Little medication was being administered at the time of the visit, and procedures described for the monitoring, management and administration of medication were sound and were reflected by the home’s policies. The new Nurse Manager had reviewed the amount of medication being held by the home, and a great deal of stock had been disposed of appropriately. The home has a contract for the collection of old stock, and appropriate arrangements are made for the disposal of controlled drugs and licensed stock. Discussions and records available evidenced that clinical input was sought for clients when required, and notifications as required under regulation 37 of the Care Homes Regulations 2001 received by the CSCI Surrey Local Office evidenced that appropriate action was taken by the home in the event that a client was believed to require emergency treatment, or when the home could no longer meet the clients clinical needs. Resuscitation and defibrillation equipment is available at the home, and nursing staff were trained to use this equipment. However to ensure that the nursing team remain familiar with its use in a range of locations around the home and the grounds, the nursing team must arrange a number of practice sessions throughout the year. In light of the nature of the treatment provided by Life Works Community, the nursing team must have policy and procedure with regard to invasive treatments and the management of epileptic seizures. The home employs a clinical team that includes counsellors to support the clients during their treatment. One-to-one counselling sessions form part of the treatment programme as well as a range of group sessions. A range of therapeutic techniques were being used during sessions. The CSCI has had concerns at previous inspections about the manner in which therapeutic and counselling sessions were run at the home. The registered Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 19 persons had reviewed this since the last inspection and there was better clarity about roles and responsibilities during sessions. Clients met during the visit raised no concerns about their treatment. Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. Although the management of complaints and adult protection was better, further areas of improvement were identified within the policies and procedures. EVIDENCE: The need to review the homes complaints procedure had been a requirement carried over from the last two inspections. The inspector was advised that this would have been completed by January 2006, however this review had not been completed. The member of staff responsible for undertaking this work had since left the organisation, and the inspector was disappointed by the lack of progress made on this requirement prior to and following the member of staff leaving. A client complaint procedure was available within the new service users guide. It appeared that this procedure had been modelled on complaints procedures obtained from Primary Care Trusts and as a result was over complicated and used a different procedure for types of complainant and types of complaints. This made the procedure confusing and involved to long a chain of people for service users to speak to. The home must review its complaints procedure without further delay, and must ensure that the procedure offers clarity and simplified procedure that simply states how anybody can make a complaint to the home, who they should make it to, and what action they should take next in the event that they remain dissatisfied with the outcome. The procedure must also refer to the CSCI Surrey Local Office and any ombudsman that can be contacted in the Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 21 event complainants remain dissatisfied with any investigation undertaken by Life Works Community Limited. Clients met were aware that they could raise their views and concerns during the weekly client meeting, and they knew where they could find the home’s complaints procedure. However the registered persons would be advised to include details of how concerns and views could be raised near to the complaints procedure so that clients can be reminded to talk to staff as issues arise. Evidence available at the time of the inspection demonstrated that the home was now responding more swiftly to complaints made, and the responses were open and more factual. Complaint records evidenced that resolutions were also being reached sooner. Staff had completed training in the protection of vulnerable adults and a member of staff had attended a “train the trainers” course in order that updates and induction training in the protection of vulnerable adults could be offered promptly. The home has been subject to an ongoing investigation under Surrey’s safeguarding procedures for over 12 months. This investigation had been closed in March 2006, and requirements and recommendations made for improvement to practice and procedures within the home, made as a result of this investigation, had been subsequently met by the home. There had been great improvement in the manner in which the home managed safeguarding referrals, and two recent incidents had been referred promptly and appropriately. Neither of these incidents were taken up for investigation under the safeguarding procedures. As a result of these separate safeguarding referrals two members of staff were dismissed by the home, and three members of staff (one retrospectively) had been referred for inclusion on the Protection of Vulnerable Adults Act (POVA) list. Although the inspector had no concerns about the recent management of safeguarding referrals, the protection of vulnerable adults procedure made available to staff did not fully meet the National Minimum Standards for Younger Adults in that it did not accurately or fully reflect Surrey’s safeguarding procedures. This policy must be further reviewed to ensure that it reflects Surrey’s safeguarding procedures and should include references to the home’s disciplinary and whistleblowing procedures. Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 22 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 excellent. This judgement has been made using available evidence including a visit to this service. The home is decorated to a high standard and well maintained. EVIDENCE: The home continued to be decorated to a high standard, and further redecoration of bathrooms and hallways had been completed since the last inspection. Clients share bedrooms in groups of two or three, and the clients met confirmed that they had been advised that they would be sharing a bedroom prior to admission. A large garden area is available for use by the clients. The inspectors were advised that sessions take place in the garden when appropriate. A spiritual garden is available and a patio area with seating and tables. Office and staff rooms are separate from the main areas of the home, apart from in the Cottage, where clients use a multi-purpose room for sessions as part of the life renewal week. Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 23 The arrangements for the completion of laundry had not changed since the last inspection. Appropriate door restraints had been fitted to the laundry door, so that they would close automatically in the event the fire alarm was sounded. The laundry is cited in a separate room, that has hand washing facilities available. Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 24 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 adequate. This judgement has been made using available evidence including a visit to this service. The staff training programme better supports service users, however, the recruitment procedure must be improved. EVIDENCE: Personnel files for the most recently appointed members of staff were sampled during the visit. Gaps were again observed in the checks obtained prior to the member of staff commencing work. Only one written reference had been obtained before these members of staff had commenced work, and although POVA first checks had been obtained for two of the three most recently recruited members of staff, no supervising member of staff had been identified for the period until a full CRB check had been obtained. One member of staff had commenced work with neither a CRB check nor a POVA first check, although evidence was available for the request of a POVA first check having been made several weeks previously. CRB applications had been made in all cases. Requirements have been made in previous inspections with regard to the home’s recruitment procedures. The registered persons must ensure that staff do not commence work until two written references and a CRB check has been applied for, with in the least a POVA first check having been obtained. Where Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 25 staff commence work with a POVA first clearance, a member of supervising member of staff must be identified to oversee the member of staff. Clinical staff recruited by the home have completed certified courses in counselling and specialist treatment for a range of addictions. Not all support staff have had experience of supporting vulnerable people, however, the home only recruits support staff who have had previous experience of being in treatment which assists them to empathise with the clients that the support. The nursing team are highly experienced in this field. Staff have received training in protection of vulnerable adults, manual handling and fire induction as well as specific training, where relevant, in maintaining healthy boundaries, clinical documentation, sex addiction, managing conflict, “Gorski” training, and training in working with people with eating disorders. The Manager stated that the training budget had been reviewed since the last inspection, and that all staff had access to an allocated training allowance that they can use for specific training for their role. The home has trained a member of staff as a trainer for mandatory training. Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 26 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 must have regard for recommendations made by the fire officer with regard to the separate “Cottage” building. EVIDENCE: The new manager was registered with the CSCI in March 2006. The Manager is registered on course to complete the NVQ Level 4 in Care and the Registered Managers Award, and had experience of working in this field, as well as previous management experience. The Manager is supported by the service Director and a Clinical Director and Nursing Manager. Although, service users had a number of opportunities to raise concerns and give feedback, including the monthly visits completed by the registered person, the home still did not have a formal quality assurance programme in place. Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 27 There was evidence that the home had kept the statement of purpose and the home’s policies and procedures under review, however a formal quality assurance system must be introduced. The home has a dedicated maintenance manager who has responsibility for overseeing all health and safety checks and maintenance of the building. Extensive risk assessments are held for the building, and evidence of the relevant annual checks, including gas safety, fire safety, and water checks were available. Contractors who have access to the premises, and may come into contact with service users sign appropriate agreements. The home made the report from the environmental health officer available prior to the visit, and the inspector was advised that all of the recommendations had been met, including changes to the layout of the kitchen. The home also made available the fire officers last report. The fire officer had made recommendations with regard to the staircase and safe evacuation from the upper floor of the cottage. The Manager advised the inspector that this would be resolved by the planned works to the building, however the registered persons must report to the CSCI Surrey Local Office what action they have agreed with the fire officer to ensure that this area remains safe for use. A recommendation was also made with regard to purchasing door restraints that comply with fire regulations for the doors between the dining area and the main building. At the time of the inspection these doors were still being propped open. The fire officer’s recommendation must be complied with without further delay. Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 28 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 1 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 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 N/A 13 N/A 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 29 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5 Requirement Once the final draft of the statement of purpose and the service users guide has been published a copy must be forwarded to the CSCI Surrey Local Office. The Manager must review the times of use and location of the leisure equipment to ensure that this remains appropriate, especially around mealtimes. The nursing team must arrange a number of practice sessions throughout the year. The nursing team must have a policy and procedure with regard to invasive treatments and the management of epileptic seizures. The home must review its complaints procedure without further delay, and a copy of the reviewed complaints procedure must be forwarded to the CSCI Surrey Local Office. This is a requirement carried over from the last two inspections with a timescale of 20/11/05, and is now an immediate requirement. DS0000059060.V295742.R01.S.doc Timescale for action 09/07/06 2. YA14 12 09/07/06 3. 4. YA20 YA20 12(1), 13(1) 12(1), 13(1) 09/07/06 09/07/06 5. YA22 22 09/05/06 Life Works Community Ltd Version 5.2 Page 30 6. YA23 13 (6) The protection of vulnerable adults policy must be further reviewed to ensure that it reflects Surrey’s safeguarding procedures and should include references to the home’s disciplinary and whistleblowing procedures. The registered persons must ensure that staff do not commence work until two written references and a CRB check has been applied for, with in the least a POVA first check having been obtained. A formal quality assurance system must be introduced. The registered persons must report to the CSCI Surrey Local Office what action they have agreed with the fire officer to ensure that this area remains safe for use. The fire officer’s recommendation must be complied with without further delay. 09/07/06 7. YA34 19 09/06/06 8. 9. YA39 YA42 24 23(4) 09/08/06 09/07/06 10. YA42 23(4) 09/07/06 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 YA7 Good Practice Recommendations The registered persons would be strongly advised to quality audit comments made during client exit interviews, and publish the outcomes and representative comments in the statement of purpose and service users guide. The registered persons would be advised to include details of how concerns and views could be raised near to the complaints procedure so that clients can be reminded to talk to staff as issues arise. 2. YA22 Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Life Works Community Ltd DS0000059060.V295742.R01.S.doc Version 5.2 Page 32 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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