Inspection on 13/05/08 for Luma Care Ltd

This inspection was carried out on 13th May 2008.

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

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

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Luma Care Ltd 42 Rollestone Street Salisbury Wiltshire SP1 1ED Lead Inspector Malcolm Kippax Unannounced Inspection 13th May 2008 10:40 Luma Care Ltd DS0000070768.V361232.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 Luma Care Ltd DS0000070768.V361232.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. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Luma Care Ltd Address 42 Rollestone Street Salisbury Wiltshire SP1 1ED 01722 341031 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.lumacare.co.uk Luma Care Ltd Mr David Ferris Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service: Care home providing personal care - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability (Code LD) The maximum number of service users who can be accommodated is 3. Date of last inspection N/A Brief Description of the Service: Luma Care Ltd. was registered as a new care home in November 2007. From the home’s ‘Statement of Purpose’: ‘Luma Care presents itself to help 3 young people from 16 to 25 years old, which are experiencing difficulties as a result of a diagnosis of Asperger Syndrome, Attention Deficit Hyperactivity Disorder, Tourettes Syndrome and other associated difficulties falling within the autism spectrum’. Luma Care is located close to the centre of Salisbury. The home is an ordinary terraced property. There is no on-street parking and visitors use one of the nearby public car parks. The communal space consists of an open plan lounge and a dining area. There is a kitchen, which leads on to an enclosed, courtyard type garden. One of the resident’s bedrooms is on the first floor and the loft has been converted to provide two other bedrooms. The bedrooms do not have en-suite areas and there is a bathroom and a shower room that residents can use on the first floor. There is also an office on the first floor for staff to use. Residents receive support from the Home Manager, a Therapeutic Manager and a team of Support Workers. Information about the home’s fee structure is available from Luma Care Ltd. There is a fee for ‘Basic Care’, and the fee increases if Vocational Support, and/or Educational Support, is also provided. Copies of inspection reports can be seen on the Commission’s website at www.csci.org.uk. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We inspect a new service within six months of it being registered. This was Luma Care Ltd’s first inspection. We already knew how the home intended to operate, from the information that they gave us when they applied to be registered. After the home had been open for a few months, we asked them to complete an Annual Quality Assurance Assessment (known as the AQAA). This is their own assessment of how well they are performing and it gives us information about their future plans. We also sent out surveys to the residents and to staff so that we could get their views about the home. Surveys were returned by both people who were using the service at the time, and by seven staff members. We reviewed the information that we had received about the home since it was registered. We made an unannounced visit to the home on 13th May 2008 and met the residents and some of the staff. We looked around the home and saw some of the home’s records. The inspection concluded with a meeting with the registered manager, Mr D. Ferris, and with the home’s Therapeutic Manager. The judgements contained in this report have been made from all the evidence gathered during the inspection, including the visit. What the service does well: The two people who were using the service had only lived at the home for a few months. One of the priorities for the management and staff team has been to support them with settling into the home and making links with the local community. The feedback we received during the inspection showed that this was going well. Residents told us about new things that they were doing, such as working in a shop and going to college. One person said that they were looking forward to getting to know some new people after recently joining a tennis club. The home is well placed for people to be able to get to different activities and places in and around the city. People can walk to many of their regular events. People can follow their individual interests, such as music, swimming and cycling. Some things people do by themselves, and they receive support with new activities. One person with an interest in photography has been able to visit a flying club with a staff member. They showed us a portfolio of their Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 6 photos, which had been very well produced. People go on trips away from the home and receive support with visiting family members. People’s bedrooms reflect their interests and their choice of décor. The rooms have televisions, music equipment and computers with internet access. People can be private in their own rooms. They have their own keys and somewhere to keep things safe. The support that people want is recorded in individual plans, so that everybody is aware of what assistance is needed and how to provide it. Staff members also talk to people about things that they would like to do in the future. Within the home, residents can participate in the daily routines and household tasks. They help with the food shopping and have the sort of meals that they like. People said that they can get up and go to bed when they want to. Staff members told us that they feel that they have the right support to be able to meet people’s needs, and that they are positive about how the home is developing. What has improved since the last inspection? What they could do better: Some of the written information about Luma Care Ltd needs to be changed, so that it accurately reflects what is happening in the home, for example about how the home is staffed. Information that has been designed for the people who use the service could be personalised, and include more details that are relevant to their individual circumstances. We have made recommendations about the way that some of the home’s records are kept. This is so that they will provide better information, or present the information in a more ‘person centred’ way. We also thought that there could be a more structured approach taken in the way in which people are supported with achieving their personal objectives. This would make it easier to review the progress that residents are making, and enable difficulties, successes and future priorities to be more easily identified. Residents have registered with a local GP and dentist, although there are further developments, for example the writing of health action plans, which will help to ensure that their healthcare and specialist needs are met in the future. Residents need to be better protected by the home’s recruitment practice. In particular, there needs to be a more thorough procedure, to ensure that all the required information on applicants has been received. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 7 The lack of a contents sheet or indexing system meant that it was difficult to locate specific policies, and assess whether they covered all the relevant areas. Some policies and procedures, or the way they are implemented, need to improve, so that there are better safeguards for the people who use the service. New staff should have the opportunity to undertake Learning Disability Award Induction and Foundation training. This is so that the people who use the service benefit from staff who have completed the appropriate programme of induction for the type of service that they work in. The training that staff members undertake needs to be well documented, so that there is good evidence to show that the home’s training plan is being put into practice. 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. Luma Care Ltd DS0000070768.V361232.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 Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is adequate. People receive information about the home although some details do not reflect what is happening in practice. People’s needs are assessed before they move in, so that a decision can be made about whether the home will be suitable for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Luma Care Ltd provided us with a copy of its ‘Statement of Purpose’ when it applied for registration. A Prospectus had also been submitted, which gave more information about life in the home and the services that were available. Copies of the Statement of Purpose and the Prospectus were available in the home when we visited. The Prospectus provided good information about aims and objectives and the opportunities that people would have. Other details were less well covered and did not include all the information that would be expected in a ‘Service user’s guide’. For example, it was stated that fees are individually assessed and that ‘this can lead to some differing of fees’. There was no information about the arrangements in place for charging and paying Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 10 for additional services. The Prospectus did not refer to the home’s complaints procedure or to how inspection reports would be made available to people. The Statement of Purpose and the Prospectus both gave information about how the home would be staffed. However when we looked at the current staffing arrangements we found that these were not consistent with what was being described in the two documents. See ‘Staffing’ section of this report. Mr Ferris said that the residents’ placing authorities had not provided any formal written assessment information prior to admission. He recognised that this was not an ideal situation. Mr Ferris had previously worked with the two residents in another setting and had undertaken his own assessment of their needs. Information had also been gained from the residents’ families and during the trial visits that people had made to the home. Information had been written down by Mr Ferris about people’s assessed needs, under headings such as Health, Medication, Nutrition, Mobility and Social Interaction. The assessment records did not show the actual date(s) of the assessment, who had contributed to the assessments and how the people who use the service had been involved and whether they were in agreement. We saw that Luma Care Ltd had produced a form for the recording of their own pre-admission assessments. However these had not been completed in respect of the current residents. The people who used the service told us that they had settled in well and got to know the home and the local area. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good overall. People’s needs are set out in individual plans, so that there is guidance for staff about how people like to be supported. People can make decisions about their lives and are supported to take risks as part of an independent lifestyle. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents had personal files, which included a range of individual plans, risk assessments and other written guidance. One of the key documents was the Placement Plan, which each resident had contributed to producing. There were also ‘Holistic Development Plans’ and ‘Individual Social Plans’. The plans and other written guidance provided information about people’s needs and their personal goals. There was no contents sheet for the personal files, and it was not clear how the different plans and risk assessments were linked, in order to give a good overview of a person’s individual needs and the support that they required. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 12 The people who used the service told us that they did not have their own copies of the individual plans, but knew about these and where they could be seen. People told us about the daily routines in the home and their activities in the community. They could not think of any house rules and said that they could get up and go to bed when they wished. The residents did not have any planned activities during the morning when we visited on 13th May 2008 and were able to get up when they wanted. People used the kitchen to make their own breakfasts and said that they could make their own drinks and snacks during the day. People told us that they had some of the main meals together; they made suggestions about what they would like to eat and these were then included on the weekly menu. In their surveys, the residents confirmed that they could do what they wanted to do during the week and at the weekends. We saw that people had keys to their own rooms and that there were no restrictions on where they could go within the home. People told us that they also had keys to the front door. One person said that they went to a local college independently each week. We saw that a risk assessment for this had been completed and a record kept on their personal file. Risk assessments had been undertaken for other activities and the use of certain facilities. The assessments focussed on the hazards associated with a particular activity; however the benefits for the person were not highlighted in the same way. Both residents said that they went out independently and were able to decide how they wished to spend their time. They had agreed objectives, which had been written down in their Placement Plans. People told us how they managed their own money. This included being able to access cash, without the need for a staff member to be involved. They had their own mobile phones. Mr Ferris said that people could also use the home’s own phone and that there would be no charge for this. The residents received individual support from keyworkers, who they met with regularly. Records of the meetings were being kept. They showed that people could talk about the progress that they were making and about new things that they wanted to do. Luma Care Ltd DS0000070768.V361232.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 overall. People have been well supported with settling into the home and the local community. People are asked about their personal objectives and will benefit from the programme of support that is being developed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who used the service told us how they spent their time. The home was well placed for people to be able to get to different activities and places in and around the city. People could walk to many of their regular events. Their regular occupation included working in a shop and a club, and attending college courses. This meant that the residents had contact with people from outside the home. One person said that they were looking forward to getting to know some new people after recently joining a tennis club. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 14 People had other interests, such as music, swimming and cycling. Some things people did by themselves, and they received support with undertaking new activities. One person with an interest in photography had been able to visit a flying club with a staff member. They showed us a portfolio of their photos, which had been very well produced. People showed us their bedrooms, which reflected their interests and their choice of décor. They had televisions, music equipment and computers with internet access. Records in the home showed that people were being supported with finding new jobs and were learning how to deal with employers. One person had tried working in a supermarket but then decided that this was not for them. There was a copy of a letter on file, which they had written to the supermarket about this. One part of people’s Placement Plans focussed on their plans for the future. A list of short and long term objectives had been drawn up. It was not clear how these were being prioritised over time, and what steps people would need to take in order to achieve the objectives. Mr Ferris said that particular objectives were being monitored through the Individual Social Plans. We talked to Mr Ferris about having a more structured system in place, which would enable progress and achievement to be more objectively measured. Within the home it was expected that residents would participate in the daily routines and household tasks. People helped with the food shopping and with preparing meals. They could do their own laundry. Details of the home’s visiting arrangements were included in the Prospectus. We heard from the residents about the visits they made to family members. Details of people’s important relationships and contacts had been recorded in their personal records. A weekly menu was being produced, with appropriate details recorded. Residents could help to choose the meals. We heard that somebody had a preference for convenience type foods and another person liked to have more freshly prepared dishes. People told us that their individual preferences were being taken into account. They could eat independently and nobody needed support with special diets. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good overall. People are receiving the support that they need with their healthcare and medication, although some further developments would be beneficial. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We were told in the AQAA that people did not require support with their day to day personal care. The people we spoke to in the home confirmed this to be the case and that the residents did not have any physical care needs. When we visited, residents were managing their own personal care routines. People had the privacy of their own rooms. They had chosen what to wear and appeared to be confident about their personal appearance. The staff that we spoke to said that they had no concerns about people’s health and physical wellbeing. We were told that the residents could manage their own nail cutting, but that staff were aware of the need to monitor how well this was being done. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 16 Residents had registered with a local GP and dentist since moving into the home. Their contact with health professionals was recorded in daily records. We talked to Mr Ferris about the specialist support that people needed. We were told that contact had been made with a local social services team in connection with psychiatric support. We discussed the possible involvement of the Community Team for People with Learning Disabilities and also spoke to Mr Ferris about ‘Health Action Plans’. These are designed to ensure that arrangements are in place for people to access the health care and professional support that they may need at the present time and in the future. There was a written policy on medication and a procedure for its administration. There was suitable cabinet for the storage of people’s medication. Nobody was looking after their own medication, although a risk assessment for self-medication had been undertaken. Residents had not signed consent forms to confirm their agreement to the present arrangements and the involvement of staff. We looked at the medication administration records. On occasions, one staff member had initialled the record and at other times two staff members had. We were told that this reflected whether there was one or two staff present at the time, although this system did make the record look incomplete. There was no PRN (‘as required’) medication being administered. The administration of homely remedies was being recorded, although the residents’ GPs had not yet approved the list of products. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate overall. People are listened to and know what to do if they have any concerns. Procedures have been put in place to protect people, although some have not been as thoroughly applied as they should have been. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We asked the people who used the service about the home’s complaints procedure. They mentioned that information was displayed about this in one of the communal areas. Luma Care Ltd had produced a complaints leaflet, which mentioned people who the residents could talk to if they had a problem with something, or wanted to make a complaint. A telephone number was given for the Commission for Social Care Inspection, but not the address. In their surveys, the residents confirmed that they knew who to speak to if they were not happy. Residents had the opportunity to raise any concerns during regular meetings with staff and with their individual keyworkers. It was reported in the AQAA that minor complaints had been raised and addressed. We asked Mr Ferris about how these were recorded and were told that they would have been noted in the daily reports. It was agreed with Mr Ferris that it would be useful to keep a separate record of any concerns, or compliments raised, as this would make it easier to keep an overview of the sort of issues that people were raising and how these were dealt with. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 18 It was reported in the AQAA that the home had not been involved in any safeguarding referrals or investigations since it opened. Luma Care Ltd had produced written polices, which covered topics such as behaviour management, physical intervention (restraint), protecting people from abuse, and whistle blowing. Mr Ferris said that no physical interventions had been needed since the home opened. Mr Ferris has attended a ‘train the trainers’ course in Therapeutic Crisis Intervention. This course is designed to support people in managing challenging behaviour through distraction techniques. Training for staff in this subject was included in the home’s training plan for the year. The home admitted people from the age of 16, which meant that there were other policies and procedures that needed to be in place concerning the protection of children. A policy and guidance had been written in connection with child protection, although this appeared to have been produced without reference to the procedures that have been agreed by the Local Safeguarding Children Board (formerly the Area Child Protection Committee). The home’s policy included the addresses for child protection within the neighbouring counties of Hampshire and Dorset, rather than referring directly to the relevant authority within Wilshire. In their surveys, the staff told us that they knew what to do if somebody had concerns about the home. We met staff who told us that that the procedures about protection had been gone through with them during their induction. The home’s training plan included in-house training in ‘Protection from Abuse’ and arrangements were being made for staff to attend an outside course as places became available. One member of staff told us that they were booked to go on a day’s course during that week, which had been arranged by the local authority. We talked to Mr Ferris about the home’s recruitment procedure. He confirmed that it was the policy to check the names of successful applicants against the Protection of Vulnerable Adults (POVA) list and also the Protection of Children Act (POCA) list. However when we looked at the recruitment records we found that POCA checks had not been requested for all the staff. See ‘Staffing’ section. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 and 20 Quality in this outcome area is good overall. People live in a suitable environment and have accommodation that suits their needs. The home is generally being well maintained, although people may need more support to ensure that items in need of repair are quickly identified and responded to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Luma Care Ltd is located close to the centre of Salisbury and was well placed for people to be able to get to their planned activities. People told us about the different places that they went to independently, and the local shops that they used. A lack of parking outside the home was one drawback for visitors and staff, although there were some public car parks nearby. Nobody was reported to have any physical disabilities and the property had not been adapted because of this. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 20 The communal space consisted of an open plan lounge and a dining area. These had been furnished and decorated in a modern and co-ordinated style. The rooms looked clean and tidy, and the overall appearance was one of a well maintained interior. There was a domestic type kitchen, which the residents could use. At the back of the property there was a small courtyard type garden with patio chairs and a table. We saw that residents were using the communal and domestic areas, as well as their own rooms. Residents showed us their rooms and said that they were satisfied with the accommodation. They had chosen the colours and the rooms looked light and airy. People had been provided with small safes when they could lock things away. One of the residents said that their room was larger than they had been used to, which they liked. The home’s Statement of Purpose included some information about the accommodation, but did not have details about the sizes of rooms. The bedrooms did not have en-suite facilities. It had been decided at the time of registration that as a ‘small, family type home’, en-suite facilities would not be a requirement. There was a bathroom and a shower room that residents could use on the first floor. We saw in one of the bedrooms that part of a window frame had broken, exposing the edge of the pane of glass. The occupant of the room told us that they were not aware of it being a problem and that it had not been reported to staff. There were privacy curtains fitted, which meant that the damage was not immediately visible. Mr Ferris was concerned that this had not been picked up on earlier, although it was not clear how long the window had been broken for. Mr Ferris made arrangements quickly for a contractor to visit and we later saw that the window had been repaired. Mr Ferris has reported that new double glazed windows are to be fitted in the bedrooms, and throughout the home during the next 12 months. Laundry was carried out in an area beyond the kitchen and there was a procedure to follow for the movement of washing, to avoid the risk of crossinfection. We were told that an Environmental Health Officer had arranged to inspect the home. Since we visited, Mr Ferris has confirmed that this inspection was carried out and that there were no requirements or recommendations made at the time. When asked in their surveys whether the home was fresh and clean, the residents responded ‘always’. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. People have not been fully protected by the home’s recruitment practices. Staff members are increasing their skills and knowledge but people in the home do not yet benefit from an appropriately trained staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff we met told us that they had received an induction when starting in the home. Some records had been kept as part of the supervision of new staff, although a formal induction programme checklist was not being completed. Luma Care Ltd had produced a ‘Personal Development Plan’ recording form, although this was not yet in use. We discussed the home’s induction programme with Mr Ferris and advised him of Learning Disability Award Induction and Foundation training, which is the expected standard for staff who are working in a learning disabilities service. It was reported in the AQAA that the home did provide induction training that met the national minimum standard for their service. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 22 In their surveys, all the staff confirmed that they were being given training which was relevant to their role, helped them to understand and meet the residents’ individual needs, and kept them up to date with new ways of working. Six staff reported that they always felt that they had the right support, experience and knowledge to meet the different needs of people who used services. One person had reported that this was usually the case. A training plan had been produced, covering the period November 2007 – December 2008. This was a costed programme, in terms of staff time and also the finances involved. The programme covered a wide range of topics, including health and safety related subjects and other training events related to the specialist needs of the residents. We had read about the home’s staffing arrangements in the ‘Statement of Purpose’ and Prospectus. Support Workers’ qualifications were listed in the Statement of Purpose as including National Vocational Qualification (NVQ) at Level 3. However it was reported in the AQAA that staff were still to complete an NVQ at this level, although 50 of the permanent staff had achieved NVQ at Level 2 or above. In the training plan it was stated that 80 of staff were to have achieved NVQ at Level 3 by December 2008. It was reported in the Prospectus that staff within Luma Care will have a minimum requirement ‘of at least two years in an autism specific service’. However, not all the staff had been recruited with this level of experience. We looked at examples of the staff members’ employment records and the documentation they contained. Staff members had completed an application form. Written references and proof of identity had been obtained, although there was no evidence that the people appointed were physically and mentally fit for the purposes of the work. Staff members’ Criminal Record Bureau (CRB) disclosures had been retained in the home. We advised Mr Ferris of the arrangements that should be made concerning their retention in the future, after the relevant information from them has been recorded. We looked at the disclosures for 11 staff who had been appointed since the home opened. There was evidence that checks of the Protection of Vulnerable Adults (POVA) list had been undertaken. However the CRB disclosure records showed that checks of the Protection of Children Act (POCA) list had not been requested for two of the staff. We discussed this with Mr Ferris, who followed it up with the umbrella body that were involved in obtaining the CRBs. Mr Ferris confirmed with us the arrangements that would be made in respect of staff concerned, until new POCA checks had been completed. The people who were using the service at the time of the inspection were both over the age of 18. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 23 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, 38, 39, 40 and 42 Quality in this outcome area is adequate overall. People generally benefit from the way that the home is run, but there are areas that require attention to ensure that their best interests are safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mr Ferris was registered as manager when the home opened in November 2007. As part of the registration process, the applicant is required to show that they are a ‘fit person’ to manage the home. ‘Fitness’ refers to a number of personal attributes, such as having integrity and being of good character. The applicant will also have demonstrated that they have the qualifications, skills and experience that are necessary for managing the care home. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 24 It was evident from our discussions and observations during the inspection that a priority for Mr Ferris and the staff team had been to support residents with settling into the home and with establishing links with the local community. The feedback we received from the people who use the service, and from the staff, was that this had gone well. Information had been included in the AQAA about the home’s plans for the next 12 months and what could be done better. This showed that the home was able to identify ways in which it could improve. Residents were being given the opportunity to express their views although a planned system for quality assurance had not yet been implemented. Mr Ferris said that there were plans to use questionnaires later in the year in order to get people’s views about the home. Regular audits were also to be established. The outcome of the home’s quality assurance systems will be looked at during a future inspection, after it has been implemented and an annual development plan produced. A range of policies and procedures had been written and were kept on file. However, the lack of a contents sheet or indexing system meant that it was difficult to locate specific policies and assess whether they covered all the relevant areas. Some policies and procedures had not been produced, or implemented, with reference to the appropriate standards and regulations. There was a policy on health and safety. Other policies had been produced for specific areas such as the control of substances hazardous to health (COSHH), fire safety and infection control. Risk assessments were being undertaken in connection with the environment and facilities, as well as concerning the residents’ individual activities. Some regular safety checks were being carried out, including the testing of the fire precaution systems. As reported under the ‘Environment’ section, there was a broken window in one resident’s room. Checks of the gas and electric appliances had been carried out. Fire drills were being undertaken and staff had received instruction in the fire procedures. These, and other fire safety activities, were being recorded in different ways and we talked to Mr Ferris about recording all the fire related activities in a single log book. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 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 X 34 2 35 2 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 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X N/A 2 X 2 X Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 6 Requirement The contents of the Statement of Purpose and Service user’s guide (Prospectus) must be reviewed, and where appropriate, revised. This is to ensure that the contents are accurate and that people are provided with the appropriate information. 2. YA22 22 The home’s complaints procedure must include the address for the Commission for Social Care Inspection. A copy of the amended procedure must be given to each person who uses the service. 3. YA23 32 The home must have child protection procedures that are in line with the local policies and procedures agreed by the Local Safeguarding Children Board (formerly the Area Child Protection Committee). There must be documentary evidence of the training that each staff member has undertaken. 30/06/08 30/06/08 Timescale for action 31/07/08 4. YA35 19(5) Schedule 2 30/06/08 Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 27 5. YA34 19(5) A prospective staff member’s name must be checked against the Protection of Children Act (POCA) list, as part of the home’s recruitment procedures. This is to ensure that people in the home are not at risk of being supported by somebody who is not suitable to be working with children. 15/05/08 6. YA34 19(5) A prospective staff member must 15/05/08 provide a statement as to their physical and mental health, as part of the home’s recruitment procedures. This is to ensure that they are physically and mentally fit for the purposes of the work they undertake. 7. YA42 23(2)(b) The registered person must ensure that items in need of repair are quickly identified and responded to appropriately. This is to ensure that residents are not at risk of being harmed by having contact with broken items. 15/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations That people who use the service are provided with their own personalised copies of the Service user’s guide (Prospectus). This is so that each person has information that is specific to their own situations and reflects their individual circumstances. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 28 2. YA2 That the pre-admission assessment form is amended in order that more details can be recorded about the circumstances of the assessment. This is so that there is better information available about the involvement of people outside the home and the views of the people who use the service. 3. YA6 That a system of cross-referencing is used in the residents’ records, for example between the Placement Plans, Social and Holistic Plans, and the risk assessments. This is so that all the information and guidance relating to a particular need or activity is easily identifiable and presented in a more ‘person centred’ way. 4. YA9 That the benefits of participating in a particular activity or task are highlighted, in addition to any hazards. This is so that risks are assessed in a balanced way, which reflects the rights of the people involved. 5. YA11 That there is a more structured approach to the monitoring and recording of the progress that people make with achieving their identified objectives. This is so that it will be easier to review the overall progress that residents make with achieving their objectives. It will enable any difficulties, successes and future priorities to be more easily identified. 6. YA19 That a Health Action Plan is completed with each resident. This is to ensure that arrangements are in place for people to access the health care and professional support that they may need at the present time and in the future. 7. YA20 That the residents’ consent to the administration of medication by staff is obtained and recorded. This is so that the residents’ rights are respected and are given the opportunity to control their own medication, where appropriate. 8. YA20 That the residents’ GPs are asked to approve a list of homely or ‘over the counter’ remedies that can be administered to residents in the home. This is to ensure that homely remedies can be safely administered and will not produce an interaction with any prescribed medication, which could be harmful. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 29 9. YA22 That a separate record is kept of the ‘informal’ concerns and compliments that are made by the people who use the service. This is so that it is easier to keep an overview of the sort of issues that people are raising and how these are being dealt with. 10. YA34 That a recruitment / employment checklist is completed with applicants. This is so that it will be easier to maintain an overview of the recruitment process and whether all the appropriate checks have been undertaken. 11. YA35 That new staff have the opportunity to undertake Learning Disability Award Induction and Foundation training. This is so that the people who use the service benefit from staff who have completed the appropriate programme of induction for the work they undertake. 12. YA40 That new policies and procedures are produced with greater reference to the relevant regulations and guidance. This is to ensure that the policies and procedures are consistent with the standards that need to be met in the home. Luma Care Ltd DS0000070768.V361232.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Luma Care Ltd DS0000070768.V361232.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. 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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