Inspection on 25/08/05 for Matson House

This inspection was carried out on 25th August 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Matson House 23/01/07

Matson House 23/05/06

Matson House 01/12/05

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 GL4 6ED Lead Inspector Tanya Harding Announced 25 August 2005 10:00am th 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 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 Stationary 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 D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Matson House Address Matson Lane Matson Gloucester GL4 6ED 01452 307069 Telephone number Fax number Email 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 Ltd. Mrs Jenny Handsl Care Home 13 Category(ies) of LD - Learning Disability Both (13) registration, with number of places Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2005 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 Organisation’s 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. A new registered manager has been appointed in June 2005. 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. Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection commenced at 10.00 and lasted approximately six hours. The lead inspector was accompanied by Business Services Senior Administrator. The newly Registered Manager as well as the Care Director helped with the inspection. Both George and Charles Houses were visited. There was a brief overview of the environment and an audit of various records in the home. The main purpose of the inspection was to ascertain whether sufficient and satisfactory progress has been made with addressing requirements from the previous inspection. There were four staff on duty at George House, including a team leader and five service users. At Charles House there were four staff members and six service users. This included a team leader and an agency member of staff. The majority of the service users were in the home and the inspectors met and greeted almost all of them. Many of the service users have complex communication needs and some are unable to communicate verbally. Prior to this inspection the Commission was in receipt of a complaint about the service provided and this report comments on the findings and outcomes of the complaint. In recent months the Organisation has been asked to take corrective measures to improve staffing levels in the home. A weekly monitoring system has been agreed to ensure staffing rotas are forwarded to the Commission. What the service does well: What has improved since the last inspection? Changes have been implemented to the staff structure in the home. Staff had to re-apply for their positions and prove their competency in the roles they were applying for. New team leaders with significant experience in care have been employed from outside of the Company. The Organisation anticipates that these changes will have a positive impact on the quality of the service provided. Two files containing information about service users have been audited since the last inspection. Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 6 Some improvements have been made to the communal areas to make them more homely. 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 D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 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 standard(s) These standards were not assessed on this occasion. EVIDENCE: There have been no new admissions to the home since the last visit. At the time of the inspection there were two vacancies. The Organisation has acknowledged that until staffing shortages are rectified no new service users will be placed at Matson House. Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 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 standard(s) 6 and 9 The care plans and risk assessments in place do not adequately reflect and meet the needs of service users potentially creating inconsistencies in how people are supported and compromising service users’ welfare. EVIDENCE: The home was required to audit and update the care plans and risk assessments for all service users by June 2005. This is so that the guidance provided was clear, consistent and reflected the needs and wishes of the service users. There was also a requirement for the risk assessment to be more detailed about the actions which staff must take to reduce or eliminate the dangers and hazards. This requirement has been carried over from October 2004. At the time of this inspection, the registered manager advised that files for two service users have been audited. The risk assessments have not been changed but a section about what action should be taken to reduce risks is included in the paperwork. The risk assessments which are currently in place for service users in the home are very basic and there is no evidence of a holistic approach to these. From the evidence seen in the home on this and previous inspections it is evident that some of the risks to the health and safety of the Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 10 service users have not been considered. This is a significant shortfall under the Regulation 13 (4) and 13 (6). The most obvious risks people are exposed to in Matson House are from other residents and these need to be incorporated into a risk management strategy. Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 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 standard(s) 17 There is lack of clear guidance on how service users rights must be respected and protected and this has contributed a development of an institutional value base amongst some staff potentially putting service users at risk of being disempowered and disrespected. EVIDENCE: In the last inspection report a requirement was issued to provide all staff with clear guidance on how to support service users with accessing drinks and snacks. This is because there are a number of restrictions in place in the home and service users cannot just help themselves. This requirement has been carried over from October 2004. There was also an additional requirement to ensure that all staff had an understanding about people’s rights in the home. Again this was with a particular reference to having food and drink. This is because some staff said that service users had to ask for food between meals as otherwise they would be stealing. There are still a number of restrictions in the home on service users accessing the kitchen, having to have drinks and meals at certain times and certain places in the home without an option / choice. This presents an institutionalised culture and does not support a person centred approach in line with current best practice. Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 12 The inspector was able to follow this matter up with the registered manager as well as with several staff and again found that the understanding of some staff about how to support service users to have snacks and drinks between meals differs from that of the home manager. Staff said they were unaware of any written guidance about this issue although some discussion did take place during a team meeting. The registered manager confirmed that no written guidance has been issued to the staff team. She said that some pictorial prompts have been placed around the home for service users to tell staff if they are hungry or thirsty. This is a positive step for those service users who can communicate in this way. The manager explained that the placing authority and the GP have been approached to review the dietary restrictions for one service user and further investigations are needed to establish whether the person needs a gluten free diet or not. She also said that efforts were being made to reduce the number of restrictions in the home and the inspector will look for evidence of this during future visits. The home has provided the inspector with an assessment of the environment for the home, which details why certain restrictions are in place. The requirement made in the last report about appropriateness of an activity timetable is no longer relevant as it referred to a specific individual who has since moved from the home. Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 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 standard(s) These standards were not assessed on this occasion. EVIDENCE: The requirements made by the pharmacy inspector in the last report will be assessed at the next visit. The manager advised that one service user is being supported to manage own medication. Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 14 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 standard(s) 22 and 23 Arrangements for protecting service users are not satisfactory, putting them at risk of harm and abuse. EVIDENCE: Prior to the inspection the Commission had received a complaint from another care provider about the standards of care in Matson House. The complaint has now been investigated and the findings are outlined below. 1. Concerns were raised that staff did not offer appropriate and respectful support to a service user during breakfast on 6th July 2005. It was not possible to obtain further evidence of poor practice on the specified date. However, the Commission could not rule out poor practices in the home as evidence of this has been commented on in two previous inspection reports. This part of the complaint has been partially substantiated. 2. An incident when a staff member allegedly pushed a service user, as witnessed by the complainants. In the course of the investigation is has not been possible to establish what had happened with regards to the alleged incident. However, this was a serious allegation and could not be dismissed. The Commission has found it to be unsatisfactory that no staff have been identified who can corroborate or discount the allegations. This part of the complaint has been unresolved. 3. Staff members assisting with the assessment not having sufficient knowledge of details about the specific service user. Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 15 The investigation found that at least one staff member present during the assessment on the day in question was very new and would not yet have had the necessary knowledge. Other staff present would have been fully aware of the information and how to access this on file. This part of the complaint is unresolved. 4. Concerns were raised about the practice of stepping over a specific service user when the person chooses to lie on the floor. This part of the complaint is upheld, in that the inspectors too had witnessed such practice during a visit to the home. Staff also confirmed that one service user tends to place himself on the floor. This issue has been discussed with the home management and a requirement is made to review the circumstances under which the service user places themselves in this very vulnerable position and take action to ensure the person’s safety, welfare and dignity are protected at all times. 5. Inadequate staffing levels. This part of the complaint has been upheld. Although on the day of the complaint there were sufficient staff on duty, there was evidence that staffing levels were not always adequate, as seen in rotas and from discussions with care staff. The Commission has made requirements for the home to improve staffing levels and is continuing to monitor that adequate staffing levels are being maintained. 6. Concerns were raised about cleanliness and upkeep of the home environment. The inspectors found that the general appearance of the plaster on walls and ceilings was not satisfactory and damage was seen in several places. The Commission has been made aware that work to repair this damage and to redecorate the corridors and other areas has now commenced and was due to be started as part of the companies on-going maintenance programme. A stained carpet in one bedroom has been replaced. The building is a large listed building and an on-going maintenance programme is essential. This part of the complaint has been partially substantiated. There are a number of requirements made in this report in response to the above findings. The Commission also hopes to discuss with the home at the forthcoming meeting the procedures for investigating complaints and following up concerns to ensure these are effective and robust. Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 16 The Commission remains highly concerned about the ability of the home to manage people who display violent and challenging behaviours. There have been a number of requirements made in past reports for the home to improve their procedures for managing physical interventions, responding to aggression by service users and monitoring the number and nature of violent incidents in the home. There were also requirements made to ensure that when service users in the home are hurt as a result of an incident or are attacked by another person in the home, there must be a process of notifying other significant people who can advocate on behalf of the service users. Because the majority of the service users in Matson House are not be able to self advocate, the home was asked to establish a process of formally notifying the placing authorities and families. To date there is no evidence that this is happening even though the Commission was given assurances that such protocols would be implemented. In the past few months the Commission has been monitoring how the home is managing two specific service users who have been posing significant risk to the safety and well being of other residents as well as staff. One person has now moved to another home. However, it is felt that the necessary action was not taken quickly enough and this was to the detriment of other service users. Another person is continuing to pose significant challenges in the home and the Registered manager has again been required to consult with the placing authorities and take decisive action to prevent further violent attacks on the residents in the home. With regards to the above concerns, the home has been in consultation with the local Community Learning Disabilities Team and sought advise from the psychologist to determine whether one service user can continue to be supported in the home. For another person there is ongoing multidisciplinary monitoring and the home has shown full co-operation in this process. The home has written Adult Protection procedures in place, but there has been little evidence that these are being followed. Some of the requirements made in the last inspection report under this standard were not assessed individually on this occasion and will be followed up in more detail during future visits. The Commission has requested another meeting with providers to discuss these serious concerns. Issues about protection of service users have been raised with the home previously and the Commission will take enforcement action unless a consistent and prompt improvement is seen. Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 17 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 standard(s) 24 and 30 Parts of the environment and are in need of repair, maintenance and cleaning creating a less than homely feel. EVIDENCE: At the time of the inspection a programme of re-decoration had started in George House and there were plans for this to continue throughout Charles House. This included repainting of walls, doors and skirting. There were also plans to repair walls and ceilings where the original plaster had deteriorated, as part of the companies on-going maintenance programme. The manager advised that she is planning to improve the communal areas by brightening up some of the dark panelling, having additional / brighter lighting and putting up pictures / art work. Some new artwork is already been put up and does make a welcome difference. Concerns were expressed about the cleanliness of the home and the environment in general in the last complaint received by the Commission. There were no offensive odours in the areas visited. The carpet in one bedroom has since been replaced since the complaint and plans were in place to reglaze the cracked windowpane in the same room. Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 18 The majority of the cleaning in the home is carried out by care staff although some cleaning in communal areas is also attended to by a part time cleaner. Some areas such as doors, door knobs and light switches were dirty on the day of the inspection. Due to the nature of the needs of the service users the cleaning task is considerable and has to be thorough and ongoing. Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 34 Staff shortages have impacted on the quality of life for the service users in the home and may have compromised their safety and wellbeing. The procedures for recruiting staff are still not sufficiently robust and do not provide the safeguards to offer protection to service users. EVIDENCE: The recent complaint investigated by the Commission has highlighted a significant concern around staffing numbers in the home. The Commission was not made aware of these by the Registered Provider. Prior to the inspection the Company had recruited a significant number of overseas staff who were due to start employment on 28th September 2005. As an emergency measure the company has been using agency staff to maintain minimum required staffing numbers. Staff rotas are being forwarded to the Commission on a weekly basis for monitoring. Checks such as employment history, references, Criminal Record Disclosures and a check against the Protection of Vulnerable Adults register need to be obtained for all staff before they start work in the home. These are essential steps in protecting vulnerable service users from staff who may be unsuitable. Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 20 Several staff files were examined for staff who commenced employment since the last inspection. Some of the necessary records have not been obtained for all those staff and this must be done within timescales. The home has had previous guidance and past requirements about ensuring that all necessary information is in place prior to staff commencing employment. Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39 and 43 There has been lack of effective leadership and accountability in the home over the past few months and this has resulted in development of practices which do not promote and safeguard the health, safety and welfare of the service users. EVIDENCE: Selwyn Care has grown significantly as an Organisation during the last 12 months. Two new homes have been opened in another county and this has meant that the efforts of the Directors and Responsible Individuals have been directed away from the provision in Gloucester for part of the time. The Commission has been in liaison with Selwyn Care during this period of growth and has made requirements to improve management arrangements for the homes in Gloucester. This has now been achieved through management restructuring within Selwyn Care and a new manager was appointed for Matson House in May / June 2005. Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 22 The new manager has some two years of management experience and has worked for the Organisation for some time now. The Commission has met with the Registered providers and the management of the home in June 2005 to discuss a number of concerns about the service. During this meeting assurances were given to the Commission of the intent to improve and to meet the National Minimum Standards and Care Home Regulations. This report identifies a significant number of shortcomings and critical areas where the Organisation is failing to meet the National Minimum Standards as well as failing in its duty to protect service users in its care. Many of the shortfalls could be attributed to poor monitoring and poor quality assurance systems employed by the company. For example, although Regulation 26 visits are now taking place, the quality of the information provided in the resulting reports demonstrates lack of understanding of the process and provides little useful information about the quality of life for service users. As a tool for self-regulation, this is not being applied effectively or critically to identify the necessary improvements. Quality assurance processes must be improved to ensure there are clear lines of responsibility for monitoring each aspect of the service with robust procedures for identifying and responding to shortfalls in provision. The registered manager must ensure that she is clear about her legal responsibilities and takes prompt and decisive action in line with her role and the registered status. Another meeting has been arranged with the Registered Persons to discuss improvement strategies for September 2005. Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 2 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 x x 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 Standard No 11 12 13 14 15 16 17 x x x x x x 2 Standard No 31 32 33 34 35 36 Score x x 1 1 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Matson House Score x x x x Standard No 37 38 39 40 41 42 43 Score 2 x 1 x x x 2 D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 24 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 6 Regulation 14, 15and 17 Requirement The home must carry out an audit of service users files and ensure that all necessary care information is fully updated and there is a clear acknowledgement as to who has reviewed the documentation and when. The information and guidance must be dated and signed by the person providing it / revising it. These requirements have not been met within timescale of 30th June 2005 Care plans for all service users must provide guidance which is clear and reflects the needs and wishes of the service users. Ensure that the necessary risk assessments are carried out and recorded for all service users. Not met within timescales of 31st October 2004 and later of 30th June 2005. Risk assessments must be sufficiently detailed to demonstrate that risks and hazards have been comprehensively considered. Risk management protocols must be implemented to ensure all service users in the home are Timescale for action 30th November 2005 2. 6 14 and 15 31st December 2005 31st December 2005 3. 9 13(4)(6) 4. 9 13(4)(6) 31st October 2005 Page 25 Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 protected from violence . 5. 17 16(2), 13(6) and 12(5) Ensure all staff have clear guidance on supporting service users to have access to drinks and snacks in line with the standard. Guidance must be issued to staff to ensure that their approach is consistent, respectful and promotes understanding as to the nature of behaviours displayed by the service users. Previous timescales of 31/10/04 and 30th June 2005 not met. Plans for use of medicines prescribed on an as required basis to be reviewed to ensure details such as dose, frequency, signature, date of preparation and review are completed. To be assessed at the next visit. The provision of medicines during periods of leave or absence to be reviewed to try to avoid secondary transfer within the home. Full records to be kept. To be assessed at the next visit. The process of medicine administration to be reviewed, taking into account the guidelines from Royal Pharmaceutical Society of Great Britain to ensure safe practices are followed. To be assessed at the next visit. All staff administering medication to complete a formal training course encompassing the details in this Standard. To be assessed at the next visit. Carry out a risk assessment with regards to the service user who chooses to lie on the floor. Consider all possible risks and determine actions to minimise / remove these risks. 31st October 2005 6. 20 13(2) and 17(1) 31st October 2005 7. 20 13(2) and 17(1) 31st October 2005 8. 20 13(2) 31st October 2005 9. 20 18(1) 31st October 2005 31st October 2005 10. 23 12(1) and 13(6) Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 26 11. 23 13(6) 12. 23 13(6) 13. 23 13(6) 14. 23 13(6) 15. 16. 24 30 23(2) 13(3) 17. 18. 33 33 18(1) 18(1) 19. 33 18(1) and 13(6) Ensure that causes of bruising / injury to service users are investigated and outcomes recorded. To be assessed at the next visit. Improvements must be made to recording/ reporting and investigating systems where an incident of aggression takes place. Timescales of 31/10/04 and 30/06/05 not met. The home must establish and adhere to procedures for notifying the placing authorities and significant others such as relatives or advocates when an adverse event occurs in the home. Take prompt and decisive measures to protect service users from physical and any other form of abuse by others Review Adult Protection policy and procedures to ensure that these are in line with relevant guidance. Ensure all staff are fully aware of what to do in the event of a service user being abused. Ensure that all areas of the home are decorated and maintained in good state of repair. Ensure all areas of the home are kept clean and hygienic. Review current cleaning arrangements and take action to improve these. Ensure that the minimum agreed staffing levels are maintained in the home at all times. Provide a written confirmation of the current staffing arrangements for Charles and George Houses for day and night cover for both homes. There must be clear protocols in place for accessing agency / bank staff to cover absences 31st October 2005 31st October 2005 25th August 2005 31st October 2005 31st December 2005 31st December 2005 25th August 2005 31st October 2005 31st October 2005 Page 27 Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 20. 33 18(1) 21. 33 18(1) and 37 22. 39 24 23. 39 26 24. 34 25. 23 17(1) and Schedule 4 and 19 and Schedule 2 13(6)(8) both planned and at short notice. Staff with responsibility for accessing cover must be aware of the procedure. There must be regular reviews of the staffing complement in the home to ensure that staff are present in sufficient numbers and posess the necessary skills to meet the assessed needs of the service users at all times. Evidence of such reviews must be available for inspection. The Commission must be informed of any shortfalls in agreed staffing levels at the earliest possible opportunity. Reasons for shortages and action taken to rectify the situation must be recorded and available for inspection on request. A robust and effective system for monitoring the quality of care in the home must be developed and implemented. Visits carried out under Regulation 26 must provide evidence that each aspect of the service is appraised. There must be evidence of gathering feedback from service users, their representatives and staff in oder to provide a better idea where there may be shortfalls and improvement. Ensure that all necessary recruitment checks are carried out as necessary and all required information is collated and kept for all staff . 31st October 2005 30th September 2005 31st December 2005 31st October 2005 30th September 2005 Review physical intervention 31st protocols in line with the October Department of Health Guidance. 2005 Original timescales 31/10/04 and 30/06/05. To be assessed at the next visit. Version 1.40 Page 28 Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard 6 17 20 20 20 20 Good Practice Recommendations IPPs for all service users should be reviewed and revised using person centred planning principles. Consider consulting with GPs about weight loss for service users where this has been significant. Security of the double doors to the medicine storage in Charles House to be reviewed. Issues of consent to medication to be recorded in care plans. All containers of medicines not supplied in the MDS to be dated when first opened for use. Handwritten entries on MAR charts to be signed by the authorised staff member making the entry with a signed check for correct transcription by second authorised staff member. Medicine fridge temperatures to be recorded daily. Find more appropriate storage for buckets and mops which were being stored in the communal bathroom. Monitor consistency of staff being asked to read and sign that they have read policies / guidance. 7. 8. 9. 20 30 40 Matson House D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 29 Commission for Social Care Inspection 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 D51_D03_S16500_MatsonHse_V203151_250805_Stage4_A.doc Version 1.40 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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