CARE HOME ADULTS 18-65
Manchester Learning Disability Partnership Short Breaks Service 8 Broadlands Walk Moston Manchester M40 5LT Lead Inspector
Steve O`Connor Key Unannounced Inspection 23rd June 2006 15:00 Manchester Learning Disability Partnership DS0000065264.V299164.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 Manchester Learning Disability Partnership DS0000065264.V299164.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. Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Manchester Learning Disability Partnership Address Short Breaks Service 8 Broadlands Walk Moston Manchester M40 5LT 0161 205 5286 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) Manchester Learning Disability Partnership c/o Manchester City Council Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The home provides accommodation and care on a respite basis for a maximum of four adults aged between 18 and 65 years old whose primary need for care is by reason of learning disability. The organisation must, at all times, employ a suitably qualified and experienced manager. who is registered with the Commission for Social Care Inspection. The matters detailed in the attached schedule of requirements must be completed within the stated timescales. Not Applicable. Date of last inspection Brief Description of the Service: The care home provides 24-hour accommodation and support for up to four learning disabled adults for short breaks to give their carers /families a break from their care role. The home provides this service for over 25 people. The building is a normal domestic dwelling set on a residential street in the north of Manchester with good access to local amenities. The building is accessible for wheelchair users with a through floor lift to the first floor and tracking hoists on the ground floor. The ground floor has a kitchen, lounge and dining room, toilet and shower facilities. Bedroom accommodation and bathroom facilities are also on the 1st floor with a staff sleep-in/storage room. There is an enclosed garden to the rear of the building. Information provided to the CSCI detailed that the charges for the service are £13.50 per day. Information about the service can be obtained from the Short-Break Team based at Forrester House. Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection report is based on information and evidence gathered by the Commission for Social Care Inspection (CSCI) since the home was registered in January 2006. This information includes a pre-inspection questionnaire, completed by the home and submitted in May 2006 and an unannounced site visit to the Short Break Service office on the 16th June 2006 and a site visit on the 23rd June 2006. This is the first inspection and site visit since the home was first registered with the CSCI. During the site visit time was spent talking to people who stay at the home, staff on duty and the Assistant Network Manager. Documents and files relating to people and how the home is run was also seen and a tour of the building was made. The inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the home and to decide how much work the CSCI needs to do with the home. What the service does well:
Long before a person comes to stay at the home for the first time a great deal of work has already been done, by the home and other relevant people, to make sure that the persons personal care, healthcare and behavioural/emotional support needs are known and that the staff team have the relevant skills and knowledge needed to support that person in the right way. The home is part of the Manchester Learning Disability Partnership (MLDP). This is a joint social and health service made up of social and healthcare professionals. Depending on a persons individual needs, the home may have worked with a Speech and Language Therapists to develop clear guidance on how to help a person eat safely, or an Occupational Therapist to make sure that any support with a persons mobility or moving and handling are carried out in the right way. If a person needs support to cope with some behaviour that could be challenging, then psychologists and other clinical professionals will develop clear guidance on how to reduce and cope with this behaviour. The home places a lot of emphasis on giving people choices and allowing them to make their own decisions and not have the staff making them or setting
Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 6 their own daily routines. People are encouraged to make the small day-to-day choices that give them more control such as what to wear, what to have for dinner and where to go out. Staff were seen taking time to spend with people and finding out about their day. A person’s friend came over to visit and they joined other people for the evening meal that was relaxed and staff supported those people who needed help. The home does place a high emphasis on providing its staff team with the skills, knowledge and training they require to support people in the right way. They have access to the Manchester Children, Families and Social Care department’s training programme and team as well as the training resources available within the Manchester Learning Disability Partnership (MLDP), especially in relation to health needs. If specific specialist training is required then the home will find that from other relevant professions and training providers. Each member of staff has a clear training plan that starts from a comprehensive induction, essential core training and specific training that will meet people’s needs. Trying to find out what people think about the service they use can be difficult. It is made increasingly difficult if a large number of people who use the service cannot fully express themselves or give their views through talking. The home has used a picture-based questionnaire that allows people to use signs and pictures to express their feelings about their experience of staying at the home. From this information the home developed a report that was made available to people and their carers showing how they were doing, what people liked and what they did not like. The home used this information to look at how they run the service and how the service could be improved for people. What has improved since the last inspection? What they could do better:
The home aims to provide each person who uses the home with a care plan based on needs and risk assessment that identifies peoples’ individual goals and ways that they prefer and have to be supported, especially with their personal and healthcare. Each person should have their own personal care checklist and guidance that explains how the person themselves wishes to be supported. From the examples seen, there were good examples of clear person centred guidance on personal care. However, not every person staying at the home had such detailed information and it was difficult, from reading the information, to find out much about that person, what they liked to do and how
Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 7 they should be supported. The home must make sure that it follows its own policies and procedures for developing and producing risk assessments and care planning. An important part of a persons’ stay at the home is that they are able to take part in social and leisure activities, particularly in the community. From the records of support seen in the home it was not always very clear what activities, if any the person had been offered or supported to take part in. The home must ensure that the opportunities offered to people to take part in activities have been clearly evidenced through the home’s recording procedures. The home has a way of looking after peoples’ medication to make sure that it is taken correctly. A part of this is keeping the right information and records so that everything is kept up-to-date and accurate. There are a few areas in the managing of medication that needs some changes. If handwriting the prescription details onto the Medication Administration Record (MAR) then this must be the exact information supplied by the pharmacist on the packaging. Also, all medication that is not needed and returned to the person’s home must be clearly recorded. When people come to stay at the home they bring with them the spending money they will need to go on activities such as meals and trips out. The home has a system it uses to record what money people have and what it is spent on. This record then goes back with the person so that it is clear what their money has been used for. The home must make sure that it is following its own procedure for recording and returning these records so that everyone can see they are accurate. Whilst people are staying at the home it is the home’s responsibility to make sure that people are as safe as possible and not exposed to risks or hazards that could cause them harm. There are a variety of Health and Safety regulations and guidance covering these areas as well as the CSCI’s own regulations to keep people safe in respect to the potential dangers of fire, cross infection and the building. There were a number of shortfalls in this area, especially with staff practices for dealing with soiled items and cross infection, which the home needed to put right. These are listed in the report under the ‘Environment’ and ‘Conduct and Management of the Home’ sections. Unless there is a specific identified reason for the removal of the bedroom sink taps they must be replaced within the timescales set. Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 8 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. Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 9 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 Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 10 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective users of the service are assessed to establish their support needs and whether the home can meet those needs. EVIDENCE: The Short Break service has a clear referral process that can only be accessed through the Community Learning Disability Team Care Management system. As part of this referral process a care management assessment of need is provided and the service undertakes its own in-house assessment through visits to see the proposed person and then coming to stay at the home for tea visit or overnight stays. In this way the home is able to decide whether it can meet the persons needs and determine what support, aids or equipment is required. Manchester Learning Disability Partnership DS0000065264.V299164.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 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a system and practices for identifying the support required to meet peoples’ needs and any hazards they may experience but this has not been fully followed. Risks have not been fully identified and acted upon to allow people to be supported correctly and safely. The home encourages people to make choices and decisions about their day-to-day experience of the home. EVIDENCE: As part of the referral process a Care Management Care Plan was provided outlining a person’s primary needs. From the care management and in-house assessment information is gathered and a care plan is developed. The amount and detail of the information in the care plan reflects the complexity and range of a person’s needs. Specialist guidance to meet needs around areas such as mobility, nutrition and behaviour is developed through referrals to the relevant agencies.
Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 12 As there may be long gaps in time between peoples’ stays at the home the care plans are reviewed on an ongoing basis to ensure that the information and assessed needs are still valid. Any changes in a person’s support needs would then generate a referral to the relevant agency. As part of the initial assessment process the home undertakes a comprehensive risk assessment that looks at specific areas such as moving and handling needs, falls, personal care, communication and risks associated with the community and environment. Those areas that are identified as known or potential hazards will be assessed further by the relevant specialist provider and support guidance in minimising those hazards and risks would be developed. However, a sample of peoples files and care plans were seen and examples were found where the care plan information had not been fully completed and no risk assessment had been undertaken. The home must ensure that it follows its own policies and procedures for care panning and risk assessments. The home works with the person and their family and other relevant people to find out what the person likes and does not like in terms of diet, activities, environments and communication. Through this they try to offer people dayto-day choices and decisions that reflect their needs. Restrictions of choice are only made to safeguard the person and only as a result of a full risk assessment. Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home can not show fully that it offers and supports people to participate in activities within the house and in the community that they enjoy. Visitors are welcome and the routines of the home are based on peoples’ own preferences and activities. Meals are based on peoples’ needs and choices and appear nutritionally balanced. EVIDENCE: People stay at the home for a short time to give them and their carers a chance for a break. If a person already goes to a specific day service then they will continue to go during their stay. The home stated that people have the opportunity to visit local cafes, restaurants, pubs and other amenities that they enjoy. They also link up with another short-break service to offer some flexibility in support. People also have the opportunity to continue maintaining their own independence skills through undertaking domestic tasks within the
Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 14 home, shopping, preparing and cooking meals. The activities they take part in are based on their abilities, needs and goals. However, from peoples’ files sampled during the site visit it was found that there was very little evidence to show that those people had taken part in any valued social or leisure community based activities. The home must ensure that the opportunities offered to people to take part in activities has been clearly evidenced through the home’s recording procedures. The home tries to maintain the routines that people have developed at their own homes in terms of the day services and other activities that they would normally take part in. This is reflected within the home where peoples’ routines are based on the activities they attend and their own personal preferences. Visitors are welcome to come to the home at reasonable times but the home provides a short break away from peoples’ carers/family and so would not happen on a regular basis. Mealtimes are usually taken together with staff providing any assistance required. As the home provides a service for over 20 people choice of meals has to remain flexible and is dependent on the dietary needs of the people staying at the home at the time. Information on peoples’ food likes and dislikes is used to decide the choice of meals and the home encourages a healthy balanced diet with the availability of fresh fruit, vegetable and ingredients. Manchester Learning Disability Partnership DS0000065264.V299164.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home supports people to maintain their healthcare needs but its recording systems do not fully reflect peoples’ personal care support. The medication administration system does not have all the procedures and practices in place to ensure that people are safe and maintain their health. EVIDENCE: Each person who comes to stay at the home has his or her own personal care checklist and support guidance. This sets out clearly the skills the person has and what help they need to maintain their personal care. However, from peoples’ files sampled there was an example found where a person with a high level of mobility needs did not appear to have a corresponding moving and handling risk assessment and the information in the file relating to mobility was not very comprehensive. The home must ensure that peoples’ mobility needs and support are clearly identified and evidenced. Peoples’ healthcare needs were identified prior to them coming to stay at the home. Identified health needs and the support needed to meet them are clearly identified and the input from the relevant healthcare service had been
Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 16 gained. Specific skills needed to support peoples’ healthcare needs were provided. Each person has a medication profile that lists all current medication. Changes to the medication regime have to be notified to the home prior to the person’s stay. If the medication that arrives with the person is different from that listed then the home will contact the relevant prescribing doctor to confirm the changes. All medication that comes with the person is recorded on a MAR sheet. The MAR sheets seen were accurate in recording the dosage of medication given. MAR sheets are regularly audited by the management team. There were several areas that the home does need to address with its medication systems. If they are writing the prescription details onto the MAR then this must reflect exactly the information supplied by the pharmacist or on the packaging. All medication returned home with the person must be clearly recorded. It is also recommended that a list of signatures of those staff who administer medication be kept to ensure that they are easily recognised. Only a certain grade of staff is allowed to administer medication. Training was through observation by a senior member of the team and followed a clear checklist of actions that needed to be learnt. The Short Break service was currently working with their training provider to develop a more comprehensive system of medication training. Manchester Learning Disability Partnership DS0000065264.V299164.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People are supported and given the opportunity to raise their concerns and worries. The home does not have all the systems and practices in place to ensure that people are protected. EVIDENCE: The home forms part of the Manchester Learning Disability Partnership (MLDP) Short Break service and as such links into the formal Manchester Children, Families and Social Care (MCFSC) department’s complaints procedures. This is a clear and established complaints process that people and/or their carers/families can access. Information about how to make a complaint has been made available to people and their carers. The home also has its own informal complaints process where people and carers can contact the staff or management team to discuss issues that they are not happy with or concerns that they have. The home will try to resolve any concerns directly or may require the attention of the management team. As part of MCFSC the home follows the Manchester Multi-Agency Adult Protection Procedures. The staff team have access to a rolling programme of adult protection training and are aware of the procedures to follow. As people only stay at the home for a short time a system of recording peoples’ monies and spending has been developed. The system should show clearly what has been spent on what and how much returns home with the person. An example of the recording sheets were seen and found that the
Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 18 home was not following its own procedures for returning sheets to carers after peoples’ stay. The systems for recording peoples’ monies and spending must be followed according the home’s own policies and procedures. The home has a system whereby if they find that that a person has an injury/bruise then this is recorded on a body map. This system is to help in protecting and responding to concerns about peoples’ welfare. An example was seen of an incident that required recording on a body map. However, there was no reference to the incident in the person’s daily log, it was unclear whether an incident report had been completed and copies of incident reports are not kept at the home. The home must ensure that the policy and procedure for reporting incidents are being followed. It is highly recommended that copies of incident reports are maintained at the home. Manchester Learning Disability Partnership DS0000065264.V299164.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although the home is generally clean, well decorated and maintained there are some areas that could pose a risk to people and repairs to the undertaken. The home’s infection control practices do not fully protect people. EVIDENCE: At the time of the site visit the home was having extensive refurbishment of the ground and first floor bathrooms to make them more suited for people with high mobility and moving and handling needs. The work being carried out meant that people who did not go to a day service spent the day at another of the Short Break service homes nearby. The home stated that they had discussed issues of safety with the people doing the work to ensure that people staying at the home do not face any hazards. However, during the site visit it was observed that a large saw had been left on top of a toolbox in the dining room whilst a person was in the house. This was pointed out and the ‘saw’ was stored safely. The home must ensure that any hazards resulting from the building work in the house is identified and removed if any person is staying in the house.
Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 20 The rest of the home was generally clean and well maintained and decorated. The furniture, fixtures and fittings were of good quality and created a homely atmosphere. Two of the upstairs bedrooms had hand washbasins. However, the taps were missing from both sinks. The home stated that they had requested replacement taps, and the style of tap required, from the agency responsible for the maintenance and upkeep of the building but had received no timescales for when the work would be completed. Unless there is a specific identified reason for the removal of the bedroom sink taps they must be replaced within the timescales stated in the report. The laundry facilities are located in the kitchen and so potentially, soiled items would be present where food is prepared. From discussions with staff on duty there appeared to be a number of potential problems in the way that they are dealing with soiled items. Staff are washing out soiled items in the bath, carrying soiled items in open plastic baskets and there was a lack of knowledge from the staff in good infection control practices. The home must seek information and guidance in relation to good infection control practices. These practices must be implemented and staff must be made aware and training provided in these practices. Manchester Learning Disability Partnership DS0000065264.V299164.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from having an effective and competent staff team who have the skills and knowledge required to support their needs. The home’s recruitment practices and procedures ensure that staff are safe to work with vulnerable people. EVIDENCE: The staff team is made up of an Assistant Network Manager and six support workers (made up from two grades). There is usually two staff on duty during the day but this will depend on whether the people staying at the home attend a day service. To cover staff days off, holidays and sickness cover the home employs agency workers from either the MLDP own bank or private agency staff. The MLDP bank staff covers the majority of hours and several of the staff team work for this bank and so this provides better consistency of staffing than using private agency staff. The home has access to an established programme of vocational training that is based on the Learning Disability Awards Framework (LDAF) and then the NVQ Level 2/3 Award. Both new and long-standing staff have access to the vocational courses. The home also has a system for assessing staff competence in the key areas of skills and knowledge that staff require to
Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 22 undertake their role. This includes regular job consultations, observation of their practice and a ‘mentoring’ system whereby experienced staff are given a role in developing and monitoring the competence of new staff. The system of recording competence has been further developed and will be introduced shortly. The Short Break service has an established recruitment process that includes gaining the required documentation and checks required to ensure that staff are safe to work with vulnerable people. The home has access to a structured staff induction programme that is based on the LDAF induction and foundation programme. This is currently being reviewed to ensure it meets the new standards being introduced through the Skills for Care Induction modules that will be a compulsory requirement for all care staff from September 2006. The home’s training is provided through the MLDP and MCFSC training programmes and other training providers. The staffs training needs are identified through the home’s job consultation and appraisal process where, in addition to the core training, specific training relating to peoples’ support needs are identified and provided through the relevant training provider. Each member of staff has their own training plan and log that sets out what they need to achieve to undertake their role e.g. moving and handling, food hygiene, adult protection, recording, eating and swallowing. The plan also includes their training needs for the coming year. Manchester Learning Disability Partnership DS0000065264.V299164.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has in place the systems for gaining peoples’ views on the service. Overall, the home has the management structure to ensure that the people receive a well run service. The home’s health and safety practices do not fully protect the welfare of the people who use the service. EVIDENCE: The home’s management structure has an Assistant Network Manager (ASM) who has day-to-day responsibility for the safe running of the home. They are also responsible for another home in the Short Break service. They are responsible for supervising the staff team and to ensure that standards of care are being maintained. They do this through allocating a large proportion of their time at the home working and spending time with people and monitoring the homes recording and operational systems. Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 24 They are line managed by the Team Manager who has responsibilities for the Short Break and other services within the MLDP. The service has been in discussion with the CSCI and a proposal of who to be the registered manager has been agreed. The home gathers information about the service it provides in several ways. On an informal basis the home listens to people and their carers about their experiences of the service. The care management and in-house reviews looks at the support individuals receive. The home also organises regular meetings with people and their carers to discuss their experiences. The home also undertakes an annual quality assurance exercise where people and their carers are asked to express their views on the their experiences of the service and what they feel works and does not work. From this a report is produced setting out the key point raised and an action plan should be developed on how the home will address the issues raised. The report contained a great deal of information about the views people had on the service. But it would be difficult to judge, from the information provided, whether the home had improved from the previous year. It is recommended that the home’s quality assurance system include a quantifiable analysis of the information gathered to provide a year on year measure of the quality of the service. The home stated that it undertakes a regular audit of health and safety within the home to look at potential risks and hazards. The home has separate battery operated smoke alarms throughout the house. These are tested manually on a weekly basis. They also have access to torches if the lighting fails. The home has responsibility for the health and safety of people staying at the home. They must ensure that their current fire safety measures are sufficient to protect people. In addition, it was not clear that all the required visual checks relating to fire safety were being made and recorded. The home must ensure that it is fully meeting its fire checks and recording requirements based on the latest fire regulations. The home undertook regular temperature checks of the hot water sources. However, fridge and freezer temperatures were not being monitored. Temperature checks and recording of fridges and freezers must be undertaken on a daily basis to ensure the safety of the food stored. Servicing had been carried out on hoists and lifts, gas and electrical equipment and for legionella. Manchester Learning Disability Partnership DS0000065264.V299164.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 X 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 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 3 X X 2 X Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 26 Not Applicable 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 YA9 YA6 Regulation 15 Requirement The home must ensure that it follows its own policies and procedures for completing care planning and risk assessment documentation. The home must ensure that the opportunities offered to people to take part in activities has been clearly evidenced through the home’s recording procedures. The home must ensure that peoples’ mobility needs and support are clearly identified and evidenced. 1.If handwriting the prescription details onto the MAR then this must reflect exactly the information supplied by the pharmacist on the packaging. 2.All medication returned home must be clearly recorded. 1.The systems for recording peoples’ monies and spending must be followed according the home’s own policies and procedures.
DS0000065264.V299164.R01.S.doc Timescale for action 30/07/06 2 YA12 YA13 16 15/07/06 3 YA18 13 15/07/06 4 YA20 13 15/07/06 5 YA23 13 15/07/06 Manchester Learning Disability Partnership Version 5.2 Page 27 6 YA24 23 7 YA24 13 8 YA30 13 9 YA42 13 2. The home must ensure that the policy and procedure for reporting incidents are being followed. Unless there is a specific identified reason for the removal of the bedroom sink taps they must be replaced within the timescales set. The home must ensure that any hazards resulting from the building work in the house is identified and removed if any person is staying in the house. The home must seek information and guidance in relation to good infection control practices. These practices must be implemented and staff must be made aware and training provided in these practices. 1. The home must ensure that the current fire safety measures are sufficient to protect people. 2. The home must ensure that it is fully meeting its fire checks and recording requirements based on the latest fire regulations. 3. Temperature checks and recording of fridges and freezers must be undertaken on a daily basis to ensure the safety of the food stored. 30/07/06 15/07/06 30/07/06 30/07/06 Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA20 YA23 Good Practice Recommendations It is recommended that a list of signatures of those staff who administer medication be kept to ensure that they are easily recognised. It is highly recommended that copies of incident reports are maintained at the home. Manchester Learning Disability Partnership DS0000065264.V299164.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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