Inspection on 23/05/06 for Matson House

This inspection was carried out on 23rd May 2006.

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

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

Other inspections for this house

Matson House 23/01/07

Matson House 01/12/05

Matson House 25/08/05

Matson House 07/03/05

Matson House 30/07/04

Matson House 11/03/04

Matson House 24/11/03

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 09/07/2008.

CARE HOME ADULTS 18-65 Matson House Matson Lane Matson Gloucester Glos GL4 6ED Lead Inspector Mr Simon Massey Key Unannounced Inspection 23 25 & 30th May 2006 10:00 rd th Matson House DS0000016500.V291573.R01.S.doc Version 5.1 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 Matson House DS0000016500.V291573.R01.S.doc Version 5.1 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. Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Matson House Address Matson Lane Matson Gloucester Glos GL4 6ED 01452 307069 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) Selwyn Care Limited Mrs Jennifer Hands Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Manager must access additional training & development opportunities & receive regular formal support from the Group Care Manager in order to further develop the skills in managing the care home. Details of the necessary training & timescales for completion have been agreed with the Registered Provider. 1st December 2005 Date of last inspection Brief Description of the Service: Matson House is part of the care provision offered by Selwyn Care Limited. The home is situated on the outskirts of Gloucester in the Matson area. The organisation provides residential and day care services to adults with Autistic Spectrum disorders and associated behaviours. The home shares the site with the Organisations office, another home and the day care facility. There are spacious grounds around the home, with a lake, garden, fields and a large car park. Matson House has been split into two, Charles House and George House, each occupying a separate floor of the building and each with its own staff team. There are spacious bedrooms and communal areas for use by service users, including separate kitchen, dining and lounge areas for Charles House and George House. There are also separate staff facilities for each of the houses. The home provides transport to enable the residents to access activities outside the home. The home’s Statement of Purpose and Service User Guide provide information as to the services that the home provides. The current fee range for the home begins at £1,750 per week. Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This unannounced inspection took place on the 23rd, 25th & 30th May 2006. The inspector met and interviewed the manager, deputy manager and various members of the care staff team. Staff were observed supporting and working with the service users. Records relating to care planning, medication, staff recruitment, health and safety and staff training were examined. An inspection of the environment was also carried out. Following the previous inspection in December 2005 a considerable number of requirements were issued to the home in respect of the service provided. Meetings have also subsequently been held between Selwyn Care and CSCI to discuss the action the Provider was taking. This inspection focused on the progress made towards the requirements made at the last inspection, and also looked at the majority of the core National Minimum Standards. What the service does well: What has improved since the last inspection? The home has appointed a new Head of Communication, a Training Coordinator and a Group Manager, whose role will include the supervision of the registered manager. This has resulted in a number of initiatives around training, and improved understanding around the area of communication techniques. Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 6 There is closer monitoring by the management of the staffing cover, particularly the arrangements for one to one cover provided for certain service users. Care plans have been improved with the inclusion of more details and efforts to make them more person centred. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected 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 adequate. This judgement has been made using available evidence including a visit to the service. The admission procedure ensures that people’s needs and aspirations are assessed prior to prospective residents moving into the home. This process should be followed for all admissions to the home. EVIDENCE: One new service user has been admitted since the last inspection. Assessments were completed prior to admission and a care plan developed. The service user had the opportunity to visit and stay at the home before moving in permanently. One service user has moved from the sister home on the same site into a selfcontained annex on the ground floor of George House. However this person was moved without reference to the placing authority. Although part of the same organisation and on the same site, this was a move from one registered home to another and the formal process should have been followed. The placing authority is now undertaking a review of this placement. The service user’s parent was also not informed of the move until after it had been completed Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7&9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The revised and updated care plans provide a good basis for the care planning system within the home. Improved staff training and input around communication should improve the opportunities to encourage choice and decision making for the service users. Improved risk assessments help to promote the safety of service users and increase opportunities for activities inside and away from the home. EVIDENCE: A sample of the new care plans that have been developed were examined. The plans cover all aspects of care and provide guidance to the staff on how the care and support should be provided. Staff interviewed demonstrated a reasonable understanding of the plans but it is evident that ownership of the process of planning and reviewing is still being developed. Each service user file contains a risk management protocol for agitated behaviours. Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 10 There are guidelines around the provision of snacks and drinks and also guidance around the clearing up of waste. This was a requirement that has been met from the previous inspection. Guidance is provided on communication abilities and the use of restraint. All plans are written in the first person and are signed by staff to say they have read them. All service users had regular recording completed about their activities, care and behaviours. There was some inconsistency in the recording and this is detailed under standard 23. A sample of risk assessments were seen and these were detailed and up to date. Following the previous inspection these forms have been improved to ensure that the correct information is included. All service users now have risk management protocols in place providing guidance to staff. The missing person’s forms have been improved to include photos and the additional information required following the previous inspection. In general, good progress has been made in the areas covered by these standards and the corresponding requirements made following the previous inspection. Further progress should be made as the staff team become more familiar with the care planning system, and the reviewing and developing of person centred plans. Increased staff training around autism and communication should also ensure that an effective system is maintained and further developed. Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 11 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): 12,16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Improvements have been made in the quality of the day care choices provided but greater structure and consistency is still required. Restrictions on access to the kitchen inhibit the promotion of normal routines and choice. A reasonably healthy and nutritious diet is provided but there is scope to improve choice and involvement in food preparation. EVIDENCE: Service user care plans detail the activities and interests they enjoy and each have a weekly plan that should be followed. However some of the files say that people enjoy a ”wide range” of activities, though fail to list in detail what these are. Staff were observed supporting activities and taking people out on supervised trips and it is evident that efforts are made to keep to the designated programme. The timing and frequency of activities can be affected Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 12 by a number of factors such as staff changes, service users behaviours, the weather and staff understanding of the activity to be supported. People with an autistic spectrum disorder usually benefit most from a structured and set routine, with any changes being planned for well in advance. Whilst there has been progress in this area, the increased staff training and retention provides an opportunity for further improvements in the quality of daily activities and leisure interests. Staff explained how they were still developing in-house activities such as art, music ands crafts, but admitted there can be lack of structure depending on the knowledge and experience of the staff supporting the activity. As with the previous standards it is evident that increased staff training and improved communication would help support greater choice and the clearer identifying of individual needs. This should help routines and activities to be more individually based. Staff were observed supporting and encouraging service users to undertake activities in a professional and positive manner. All staff interviewed considered that improvements in day care and leisure activities had been achieved but also demonstrated an awareness of the need, and opportunity, to improve this aspect of the care provision. Restrictions on choice and movement are appropriately recorded in individual files, with attendant risk assessments where necessary. The issue of access to the kitchens was discussed with the manager and the care staff. Due to the occasional behaviours of two service users access to the kitchens has to be controlled at present. However it was explained that when alternative placements are found for the two service users, which are currently being sought by the placing authorities, the home will take steps to provide more normal arrangements in relation to these areas. Staff also commented that they thought in future it would be possible to increase the involvement of the service users in activities and routines in the kitchen area. The home was stocked with sufficient fresh and packaged food at the times of the inspection. The menus are the same in both of the units and staff stated that alternatives were offered when they knew that a service user disliked particular food. Choice around meals and menus is one area that the newly appointed head of communication will be looking at. The food in the main fridge in Charles House was not stored correctly. Some food was not labelled correctly and some items were being stored on the wrong shelves. The second fridge in this kitchen did not close properly and this needs to be repaired or replaced. Further comments about the use of the kitchens are made under the environment standards. Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19&20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Clear guidance and recording supports service users to receive their personal care in a way that promotes their privacy and dignity. Service users are supported to access the healthcare professional they require to ensure that physical and emotional health needs are met. The home’s medication procedures and the required training that is completed by staff, protect service users. EVIDENCE: The care plans detail the support that individuals require and also provided guidance to staff on how they would prefer this to be delivered. Individual files contain details of medical appointments and also information and correspondence from outside professionals. Staff record information following appointments in to the individual files. Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 14 Medication administration and storage was examined in both units and found to be satisfactory. There is a need to record in more detail the explanation for tablets being missing from the blister packs. All staff are required by the home to complete the appropriate training before they are permitted to administer medication. Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22&23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The home responds to concerns and complaints that are raised but needs to ensure that all parents and relatives are aware the procedure to follow if they wish to make a complaint. Improved training, protocols and recording have improved the home’s ability to manage challenging behaviours but a further decrease in incidents involving aggression between service users is required before this standard can be met. EVIDENCE: The home has kept a record of complaints that have been made and subsequently investigated, and has also ensured that the Commission has been kept informed. Feedback has been provided to the Inspector that not all parents and relatives are aware of the complaints procedure that is available to them and a requirement has been made in this report that the home ensures that all families receive a copy of the policy and procedure for making complaints to the home. The requirements made in relation to standard 23 the last inspection have been actioned by the home. Recording of agitated and aggressive behaviours was generally completed satisfactorily, with close monitoring of recorded incidents being undertaken by the manager and deputy. There was a degree of inconsistency in the detail of recording, with some staff recording more information about the antecedent Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 16 behaviour and the actual incident. One incident was found where a bruise chart had been completed but not had recorded on it that injury this had probably been the result of an assault by another service user. However no other reference to this incident was found in the daily notes and no actual incident report had been completed. The paperwork relating to an incident that had occurred during the inspection was examined and whilst largely satisfactory the following observations are made. Greater consideration could have been given to explaining the triggers for the behaviour and, if the explanation was accurate, it is clear that the incident could possibly have been avoided. One member of staff described some minor injuries they incurred during the incident but no reference to these are made in the report. With the staff team having to deal with this type of incidents on a regular basis it is important that the extent of the agitation and aggressive behaviour is accurately recorded. It was also clear that whilst this incident was occurring staff needed to take measures to protect other service users and the management of this, and the effect of the physical environment, compounded the situation. Staff attempted to remain calm in order to help descalate the situation but it was clearly still a stressful situation. There has been a decrease in the number of incidents involving aggressive behaviour, both between service users and also against members of the care staff. There was evidence of this from the records in the home, the quantity of regulation 37 notifications received by the Commission, and also from discussion with members of the care staff. However, further reductions in the number of aggressive incidents are required before these standards can be met. The recording in one file showed seven incidents having been recorded since January 2006, which necessitated bruise charts being completed. Six of these described injuries that had been as a result of conflict with other service users. One service user in Charles House is being sought an alternative placement, which may be within Selwyn Care, as it has been identified that they are unsuited to group living due to the risks they can pose to other service users. Due to the frequency of the incidents involving this service user, this needs to be organised quickly. The continued risk level to other service users is unacceptable. Various measures are being put in place, which should improve the home’s skill in managing of challenging behaviours. Staff are receiving training from Studio Three, which provides accredited training in managing challenging behaviours. The home intends to have their own accredited trainer in this area eventually. Improved protocols for managing behaviours are in place in all of the files and interviews with staff demonstrated an increased awareness of good practices that are required for working with people who have an autistic spectrum disorder. The Provider has appointed a full time training co-ordinator and a full-time Head of Communication. One of the intended benefits of these appointments is an increase in staff awareness and skills in working within a specialised service. Both were interviewed during the inspection and outlined a number of Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 17 areas in which they intend to make improvements. Improved staff understanding of the autistic spectrum and improvements in the effectiveness of communication with service users should improve the quality of care provided. Examination of the rotas show that the agreed staffing levels are being maintained and where necessary this is being done with use of agency staff. Rotas and interviews with staff show that one to one staffing is being provided where this has been assessed as being required. Whilst recognising the progress made towards meeting these standards and the measures taken by the home to improve the safety and protection of service users further improvements are required to ensure that a safer environment is promoted and maintained. An integral part of this is less conflict and aggression between the service users. The home will be providing staff training on Adult Protection. Service user finances were examined during this inspection. Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24&30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Efforts are made to maintain and promote a homely and comfortable environment and an improvement has been made since the last inspection. Staff work hard to maintain a clean and hygienic home, which is not always easy due to the layout of the building and the behaviours of some service users. EVIDENCE: At the time of the inspection all parts of the home were reasonably clean and maintained and it is evident that the organisation’s maintenance team have an ongoing programme of decoration and repairs. Extensive repairs were being undertaken to the dining room area, as well as decoration being completed in other areas. The home attempts to provide a homely environment but this is not helped by the layout of the building, the behaviours of service users and also the current arrangements regarding the security of the kitchen area. All service users have large rooms and most have en-suite shower or bathing facilities. Staff explained that service users who prefer baths to showers and do not have baths, therefore use the communal bathrooms. These bathrooms Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 19 are of poor quality, with no natural light, no homely décor and worn fittings. At the time of the visit neither of the extractor fans were working and the bathrooms appeared functional and uninviting. If these bathing facilities are the main choice for several of the service users then the home needs to investigate how this environment can be improved. Both kitchens were inspected and were reasonably clean and hygienic apart from the following. The food in the kitchen fridge in George House was not correctly labelled or wrapped, and items were being stored on the wrong shelves. There was also confidential information relating to service users being pinned the walls and the inspector also found some other confidential information in one of the cupboards. To a certain extent this kitchen is also being used as an office, with considerable information being displayed on the walls. In Charles House the kitchen and dining room also function as an office with material being stored in a locked cupboard in the dining room and various notices displayed in the kitchen. The inspector was informed that the displaying of information and the use of notice boards containing information in symbol form was an area that the communication co-ordinator would be looking at to consider what improvements could be made. Some confidential paperwork was left in a kitchen drawer in Charles House and there were also a variety of information about individual service users that was displayed on the walls. All confidential material should be securely stored and the home should also consider whether some of the other material displayed in the kitchen would be better located elsewhere. The inspector was concerned about the state of cleanliness in one bedroom but noted that this fact had already been picked up by the regulation 26 visit that had been completed and action suggested. Extra cleaning facilities were being provided and other options being looked at to investigate whether the service user could be supported to maintain a cleaner bedroom. Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,&35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Steps are being taken by the home to improve the quality and co-ordination of staff training, providing a more skilled workforce who more able to meet the needs of people within the autistic spectrum disorder. Service users are protected by the home recruitment policy that complies with the current regulations. EVIDENCE: At the time of the inspection there were sufficient staff on duty and the records and rotas show that levels have been maintained. When necessary agency staff have been deployed. Service users who are funded and assessed as requiring one to one support all had designated workers at the times of the inspection. The manager and deputy manager monitor the cover on a daily basis and have taken steps to ensure that the staff team are aware of the importance of maintaining the one to one cover and that certain service users are required to be supervised at all times. Part of the role of the deputy is to meet with the early shift at 8am to ensure the correct staffing arrangements are in place. Each unit has its own team of staff who are supervised by the senior worker on duty. The seniors are receiving training in supervisory skills and are taking on the responsibility for the formal supervision of the care staff. Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 21 A full time training co-ordinator has recently been appointed and they outlined their plans for the coming months. An audit of staff training has been completed and plans are place to ensure that all staff are up to date with the required statutory courses. A new Induction Programme has been devised for new staff, and a copy of this and the attendant workbook were shown to the inspector. Mentoring training will be provided for certain staff who will take on this role for newly appointed staff. Training will also be provided in Adult Protection, Moving and Handling, Autism and NVQ. The co-ordinator is an NVQ assessor and intends to support more staff to achieve these awards. The home provides training to staff from Studio Three in the managing of challenging behaviours. It is planned that this training will eventually be provided in house by the training co-ordinator. Training is also planned around Total Communication and Signing. As mentioned elsewhere in the report, more effective and consistent use of communication techniques should improve choice for service users and have a positive general impact upon the quality of care delivered. Several staff interviewed commented that there was an increase in the understanding and insight into the managing of autism amongst the team. The recently appointed Head of Communication has also identified a number of areas and issues they wish to focus on. It is evident that considerable resources are being put into increasing the skill levels of the staff team, both through ensuring the statutory training is up to date and providing the specialist knowledge that the client group demands. The only requirement made in relation to training in this report is that the home ensure that all staff are up to date with fire safety, food handling and first aid. Two senior staff commented that the Studio Three training had been beneficial to the team, increasing confidence and understanding. They considered the regular staff meetings were very useful and helped the staff team to “pull together”. Other staff also commented that the home has had a period of fewer staff changes and that this had be beneficial to the team and to the service users. One new staff member had just started when the inspection was being carried out. This person was supernumerary to the staffing numbers, and was being mentored and supervised by the experienced staff on duty. Other staff commented that increased communication skills were helping the team to develop a better understanding of autism and the behaviours of the service users. Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39&42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Improvements in the administration and monitoring have led to more effective management in the home. Improved leadership, direction and support from the management team have improved the effectiveness of the staff team. EVIDENCE: The manager and deputy have systems in place for checking and monitoring the staffing levels, service users activities, medication administration, behavioural incidents and staff supervisions. The manager explained that action has also been taken to improve sickness absence management and also to ensure that lieu hours are only taken after agreement with the senior staff on duty. Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 23 There has also been a decrease in staff turnover during the past 10 months and the management feel this has contributed to a more motivated and consistent staff approach. Staff interviewed stated they felt well supported by the manager and deputy and could approach them over issues or concerns. The manager and deputy stated that whilst the majority of their time over recent months has been spent on improving systems and the administration structure within the home it was intended that they would both have more time in the future to spend directly working with or observing staff and service users. The main office is located on the top floor and can seem a little remote from the houses, so this would bring benefits to staff and management. All fire safety checks have been completed and recorded and all equipment has been appropriately service and maintained according to the records. The home has a full time maintenance team who respond to requests for repairs and improvements. Regulation 26 visits are being undertaken by the Director of Care, and staff confirmed that these have been unannounced. Reports have been forwarded to the Commission as required in the previous inspection. The newly appointed training co-ordinator has put forward a new Quality Assurance proposal that is being considered by the management of the service. The organisation has also recently appointed a new Group Manager who will supervise the managers of the registered homes. This is a significant change for the homes as it is intended they will receive closer supervision and support than has been provided in the past. This being due to the growth in the organisation. This appointment, and that of the Communication Co-ordinator and Head of Training, are positive and significant changes by the organisation that should support and further develop the improvement in the quality of care that is required. The manager is completing the training that was required as part of their registration and a requirement has been made that written details of this are supplied to the Commission on completion. Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 24 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 2 3 X 4 X 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 2 28 X 29 X 30 3 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 3 3 X 3 x LIFESTYLES Standard No Score 11 x 12 3 13 X 14 X 15 X 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 X X 2 x Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 25 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation Requirement Timescale for action 30/06/06 2. YA6 3. YA23 4. YA17 5. YA23 12(1)(a)&14 The home must ensure that all admissions are completed in line with the admission procedure and that placing authorities and parents are fully informed of any move 14&15 The home must continue to improve care planning system to ensure that it is effective and identifies the needs of service users 13(4&6) The home must ensure that all incidents involving service users are recorded n sufficient detail 16(2)(h&I) The home must ensure that food is correctly stored and labelled and that repairs are completed on the fridge in Charles House 12(1)&13(4) The home must provide the Commission with a timescale for the departure from the home of the two service users who are being sought alternative placements. Updates on this should be provided as part of the regulation 26 visits that are completed DS0000016500.V291573.R01.S.doc 31/10/06 31/10/06 31/07/06 31/07/06 Matson House Version 5.1 Page 26 6. YA22 22(1) 7 8 9 YA27 YA27 YA37 23(2)(b) 23(1)(a) 9(1) 10 YA421 18©(i) The home must ensure that all parents and relatives are aware of the homes complaints procedure The home must repair the extractor fans in the bathrooms The home must consider how the communal bathrooms can be upgraded and improved The manager must supply written details to the commission of the progress made toward the qualifications and training that were required as part of their registration The home must ensure that all staff are up to date with the required statutory training in first aid, fire safety and food handling 31/07/06 31/07/06 31/07/06 31/07/06 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA34 Good Practice Recommendations Staff application forms should include clear guidance about the requirement for a full employment history Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Matson House DS0000016500.V291573.R01.S.doc Version 5.1 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!