Inspection on 22/06/06 for Melbreck

This inspection was carried out on 22nd June 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 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Melbreck 14/11/07

Melbreck 20/03/07

Melbreck 25/11/05

Melbreck 04/04/05

Melbreck 17/01/05

Melbreck 01/10/04

Melbreck 04/08/04

Melbreck 28/04/04

Similar services:

Southfields

Thorndene

Insight - Eastchurch

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Melbreck Tilford Road Rushmoor Farnham Surrey GU10 2ED Lead Inspector Susan McBriarty Key Unannounced Inspection 22nd June 2006 09:30 Melbreck DS0000017623.V300875.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 Melbreck DS0000017623.V300875.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. Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Melbreck Address Tilford Road Rushmoor Farnham Surrey GU10 2ED 01252 793474 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) Robinia Care Limited Lorna Oliver Care Home 26 Category(ies) of Learning disability (26), Physical disability (26) registration, with number of places Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Twenty six (26) beds providing nursing care for people from the age of 19 years with learning disabilities (LD) and physical disabilities (PD). 25th November 2005 Date of last inspection Brief Description of the Service: Melbreck is a substantial detached property catering for service users with learning disabilities and associated physical disabilities aged between 16 and 65 years. The home is located in a rural area near Farnham. The accommodation is for 26 service users. The accommodation has 20 single rooms with three double rooms. There is a large garden with an herb garden, outdoor pool and green house all of which are accessible to service users. Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection for the inspection year 2006 –2007 under Inspecting for Better Lives. The inspection was a ‘key’ inspection and considered all the key standards, which are noted within the report. In addition the inspection report contains a judgement noting whether the home is poor, adequate, good or excellent at meeting the outcome areas of each heading. The overall outcome from this inspection was adequate. The inspection began at 9.15am and ended at 6.15pm, one inspector carried out the key inspection. A tour of the communal areas, some of the bedrooms and the garden took place. In addition information was gained through the sampling of records held by the home, these include; care plans, service user finances, staff personnel and training information and health and safety records. Observations were made by the CSCI during the day regarding the relationship between service users and members of staff. Seven (7) Regulation 43 notifications had been made by the home since the inspection of the 25th November 2005, the information provided confirmed that the home had taken appropriate action at the time of any incident. A pre-inspection report was not available, as the home had not received the request and pro-forma from the CSCI to complete. The CSCI therefore evidenced health and safety records and others in more detail. The organisation’s homes in Surrey have been subject to a review by the CSCI, a number of the matters have now been resolved or are nearing completion. These matters are now noted here more fully. 1. Resident’s finances from February 2002 to January 2005 had been of concern. The organisation has agreed with the CSCI and under Surrey County Council multi-agency procedures that recompense will be paid to all the service users in residence during that time. Payments will be dealt with on an individual basis and may take into account pro-rata amounts. 2. Payments for holidays, meals out of the home and any other additional staff costs have ensured that; (a) Holidays are either part funded by Robinia Care South or that each prospective resident will have £500 toward the cost of an annual holiday included in his or her fee. See Standard 14.4 of the National Minimum Standards for Young Adults (18-65). (b) Additional staffing costs will not be taken from resident’s own monies. (c) Residents will not fund meals out for staff nor will they pay the full cost of the meal. This as the cost of meals is inclusive in the fee; the difference will be funded directly by the resident. Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 6 3. Residents through their mobility benefits were paying for transport provision. This method had not clearly been agreed with local authorities or families and or residents. This matter has been resolved and individual agreements made with appropriate persons completed to ensure that any payment made is agreed and recorded clearly. 4. The organisation has introduced a new policy and procedure for dealing with resident finances in order to ensure that members of staff follow consistent guidance. Members of staff have received training on this matter, as have the managers of the homes. 5. The organisation has provided each home with a clear chart informing staff of what to do and what not to do in the event of an allegation of adult abuse. The organisation has agreed to revise their policies and procedures in relation to the protection of vulnerable adults to ensure they are clear, easy to follow and are in line with local guidelines. This matter had not been attended to. 6. Further training for members of staff was also agreed as part of the service review. The organisation has employed a specialist service to train Robinia Care South members of staff to communicate and engage with their residents more effectively. In particular engaging with individuals who have non-verbal communication needs. What the service does well: What has improved since the last inspection? What they could do better: Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 7 A number of requirements were made and these are noted at the end of this report. The requirements reflect that the manager and the staff team must remain aware of the need to review and update care plans and risk assessments regularly and ensure that they do not fall behind the required dates. In this instance care plans and risk assessments must be updated at least six monthly and when required if a change occurs within that period. Significantly the organisation had not reviewed and updated their safeguarding (adult protection) policies and procedures. The organisation had a number of policies that were not linked to the Surrey County Council multi-agency procedures for the protection of adults. This matter had received requirements across the organisation and the timescale of December 2005 had not been met. This is a concern as members of staff may not be clear about what action to take in the event of an allegation being made. Whilst a poster had been made available that did identify what to do and what not to do this was not underpinned by appropriate policies and procedures. The grounds and external building require work to ensure that the patio area is free of weeds and the paving stones are flat and secured. The guttering of the building required cleaning as weeds were growing in a number of areas and would affect the efficiency of the gutters. In addition parts of the external building wall had come away exposing brickwork. 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. Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further work was required to ensure that statement of purpose provided to service users and their representatives has all the information required to assist them to make a decision about moving to the home. The statement of terms and conditions were receiving attention and will make clear what service users or their representatives can expect from the home. EVIDENCE: The statement of purpose required a minor adjustment regarding staffing levels. The statement of purpose stated that ten (10) care staff and two qualified nurses were on duty each day. The statement was based on the home being full however this was not made clear. At the time of the inspection eight (8) care staff and two (2) nurses were on duty. In discussion with the manager it was required that the staffing figures note the minimum safe staffing levels and based on the assessed needs of the service users. A new service user was expected to move to the home shortly however information from the previous provider was not as full as preferred. The family informed the manager that they had copies of the care plans and other historic information and would ensure that the home received copies. The manager Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 10 reported that a pre-admission assessment had been completed during a visit to the service user. Previous discussions with the organisation had confirmed that any service user new to the home would be assessed prior to moving in. The pre-admission assessment would include any service user who was transferring from another home in the Robinia group. A number of the current residents had been transferred internally by the organisation and re-assessments had not been completed. Evidence was provided to confirm that copies of the statement of terms and conditions had been sent to the various local authorities. At the time of the inspection none had been returned to the organisation, this was beyond the date given to the local authorities for the return of the documents. The previous requirement had not been met, the organisation must ensure the next stage of forwarding the same documents to other representatives for agreement/signature or confirmation that they do not wish to sign on behalf of the service user is acted upon in order that completed documents can be placed on the service user’s file. A requirement was made that the organisation ensure the statement of terms and conditions is in place and all service users or their representatives can be clear about what the service will provide as part of the fees being paid and which elements will attract additional payments. The statement of terms and conditions now includes how transport is funded and has reduced the possibility of service users being charged for services either not provided or where an alternative is in place. The organisation had completed the task of paying back those service users who had been charged inappropriately for services that should have been free or for the cost of transport during periods when it was not available. Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments had not been reviewed and updated regularly this might mean that members of staff may not be fully aware of any changes to the service users assessed needs. The service users at this home have complex needs and most are non-verbal this means that most decisions regarding daily living must be taken by others. EVIDENCE: The manager was in the process of revising the care plans to make them more accessible. This meant that where completed service users had two current files. One file held previous information recorded, correspondence and the initial assessment. In some instances the initial assessment had been recorded as being reviewed. In discussion with the manager this was agreed as unnecessary as the initial assessment reflects the service users needs at the point of admission and would therefore not require changing. The service users changing needs, where that is the case, would be recorded and documented through the care planning process. The second file held only current care Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 12 plans. Those care plans sampled varied with regard to when they had last been reviewed and updated. Thirteen (13) comment cards were received by the CSCI from relatives, visitors to the home and placing officers. Those placing officers who responded confirmed that a care plan was in place and the staff demonstrated an understanding of the service users assessed needs. Where possible the preferences of service users had been recorded. The service users at this home have severe learning disabilities and are not always able to make clear their views and/or make decisions regarding their own welfare needs. In many instances the service users are reliant on members of staff understanding non-verbal communication. The care plans therefore reflect all areas of their lives and what support was required to ensure their assessed needs were met. All areas of daily living received detailed risk assessment however those sampled reflected a variety of dates as to when they had last been reviewed a number had not been reviewed within the six month period as required. Detailed care plans and risk assessments had been completed however the manager must remind members of staff that documented and recorded reviews are required for care plans and risk assessments at least six monthly as well as when any change occurs. The home must ensure that the required reviews are held within the expected timescale on a consistent basis. This as the service users have complex needs and any additions or other changes are crucial to ensuring their assessed needs can continue to be met. Individual confidentiality for many of the service users is problematic due to the extent of their communication and/or learning disability and information may be shared with other professionals and family members without the service users direct agreement. Where possible the service users views are sought. The care plans do document the likes and dislikes of individuals and members of staff were able to inform the CSCI how some service users indicate their preferences. The records completed by the home do not identify whether the home has met the gender, religious and or cultural needs of service users. Further checks are required to ensure that all these matters are documented and that a record is made of how the home intends to meet any additional needs arising from this work. Melbreck DS0000017623.V300875.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): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Further improvement was found and the confidence of staff and interaction with service users had improved and was calmer and more appropriate. The menu was varied and fresh produce in use. EVIDENCE: The records kept by the home evidenced that service users were attending a variety of sensory and inclusive social and leisure sessions. These varied from attending the organisations own day centre off site to taking part in activities on the site within the therapy unit at the rear of the building. Some service users were not funded to attend off site activities. The organisation had brought in external services to assist in training the members of staff in interactive communication and this had been useful. In addition the organisation had funded an external activity service to further assist staff training in providing leisure activities. Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 14 The manager reported that they had been seeking agreement from local authorities to agree that some service users could fund the external leisure activity service themselves in order to provide variety. Not all local authorities had agreed even where service users were identified as having a good level of savings available to use. In discussion with the manager it was thought the financial profile signed by local authorities may assist in gaining funding agreements. The records held by the home showed what activity had been attended by whom, when and had been signed and dated by members of staff. Transport risk assessments had also been completed evidencing a vehicle check, where service users and staff were sitting in the vehicle and where they went on the outing. A further record had also been completed when an outing had taken place however those records did not confirm where the outing had been. Completing that record would assist in confirming the information provided. The service users resident at the home have complex needs and would not be able to consider employment or formal further education to gain a qualification. Some of the service users with support would be able to indicate their view of the home and perhaps some changes they might like to see happen. Comment cards were left at the time of the inspection, it was recognised that all the service users would require assistance from another person to complete the cards. The comment cards left were pictorial. Observations were made during the day regarding the interaction between service users and members of staff. In the therapy unit members of staff were assisting service users to make music. The interaction had improved and members of staff appeared more confident. This needs to continue in order that staff skills and knowledge continue to increase and improve. A number of families remain involved with the service users and others have very little or no involvement. The care plans generally indicate the level of involvement it might be useful to use the front sheet where basic information is provided to confirm what involvement the family of any service user provides. All the family members and visitors who returned comment cards stated that they felt welcome into the home and they were able to make their visit in private. Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 15 Menus were seen and provide a four week rota. The menu was varied and ensured a range of food was provided. The menu might not be strictly adhered to and minor changes made for example a chicken meal was on the menu for the day of the inspection and this was changed to barbeque chicken and rice. Fresh fruit was being prepared for lunch, watermelon and strawberries. The menu, store cupboard and other records confirm that food is freshly prepared and provided. A number of service users require their diet to be soft, pureed or supported by additional vitamins or fluids in order to maintain their well being. These issues were recorded on the care plans and or the medication administration records. Likes and dislikes of service users were known. Further checks were required to ensure the home was meeting service users cultural and religious needs. Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 16 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 adequate. This judgement has been made using available evidence including a visit to this service. Improvement was found with regard to accessing the primary health care teams and tertiary health services, for example wheelchair services, required for service users with complex needs. Further work is required to ensure that the records for the administration of medication are clear, up to date, accurate and signatures in place. EVIDENCE: The manager has an improved awareness of the roles and responsibilities of the primary health care service particularly in relation to the provision of aids and adaptations required by the service users. Previous issues had been raised by the purchase of items by service users where they had an entitlement for provision from the health service. During the inspection staff confidence had improved and they were less worried about talking to the CSCI or carrying on their work whilst being observed. For example in the therapy room one service user was lying across a piece of soft equipment and was seen to be relaxed, another was playing with an inflatable object with a member of staff and was clearly enjoying the Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 17 play, another service user was being massaged. In another room music was playing and staff were encouraging service users to make their own music and join in. Previous observations at the home evidenced that staff were uncertain as to how to engage with service users who were non-verbal. The care plans evidence reassessments of service users by the various local authorities and contact with wheelchair clinics, speech therapists etc. Dental care and GP appointments are made regularly and as required. Some errors were found regarding the administration of medication for example signature omissions, medication administration records not updated including where medication had been revised and changed by hand. Skin care cream pots were found without a lid in some bathrooms one without a name attached this practice must stop as the possibility of cross infection was increased. One prescribed medication may have ceased this was unclear the home must review all aspects of the administration of medication to ensure information up to date, clear and signatures in place as required. The wishes and preferred options of service users and their representatives had been sought and the responses had been placed on the service user files. Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The organisation and consequently the home do not have the policies and procedures in place that ensure that service users are protected from the various forms of abuse that can occur in a residential and/or nursing home setting. Previous requirements regarding these matters had not been actioned by the organisation and further requirements were made. EVIDENCE: No complaints had been received since the last inspection. The homes procedure continues to refer complaints about the CSCI to the director of social services, the organisation had been informed previously that the CSCI has a separate complaint policy and that those wishing to access that complaint process will be advised by the CSCI how to do so. Part of the home’s policy also refers to the Inspection and Registration Unit, which no longer exists. Three respondents stated that they were unaware of the home’s complaints procedures. Of the Thirteen respondents (13) four (4) stated that they had made a complaint to the home at some point, no comments were made regarding outcomes. The home’s safeguarding or adult protection policy and procedure does not support Surrey County Council’s multi-agency procedures for the protection of Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 19 adults (safeguarding adults). A requirement had been made for completion by December 2005; the requirement had not been met. The organisation’s whistle blowing policy states that staff must refer bad practice, illegal practice etc. However it also makes clear that these matters will be investigated by the organisation. Matters noted in the policy if reported by any person must be referred to the local social services team for consideration under the multi-agency procedures and must not be investigated by the managers of the organisation. The organisation also has a sexual harassment policy that includes reference to service users, the matters contained in the policy do not refer to the adult protection or safeguarding policy and procedure. As before the procedure states that matters raised would be investigated by the organisation. A flow chart identifying that any adult protection matter must be referred to the local service services team for consideration under the multi – agency procedures was in place. This may be confusing as the policies and procedures do not support the flow chart. Other flow charts are provided for raising concerns/complaints etc these do not highlight the requirement to consider whether the matter is an adult protection (safeguarding adults) concern. Members of staff had received training regarding the protection/safeguarding of adults. Further requirements were made; it is of concern that these matters had not received the full attention agreed with senior managers of the organisation. Further requirements were made. One respondent considered that if all the procedures agreed with the organisation following the service review are adhered to positive relationships would continue. Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 20 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 this service. Further work is required to ensure that all areas, internal and external, of the home are kept in good repair at all times. Adequate arrangements are in place for access to bathrooms. EVIDENCE: A tour of the building was carried out by the CSCI, all the communal areas and grounds were viewed however not all the bedrooms were seen. The home had adequate bathrooms with aids and adaptations available to support those who would not be able to access a bath or shower. For example a shower trolley, this enables a service user to be placed on the trolley and a shower attachment used to wash the service user. All those bedrooms that were in use and seen had been personalised, some of the beds were checked and sheets and mattresses were clean. One headboard required a wash or replacement and the valance in the same room required Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 21 changing, as small marks were evident. A requirement was made to ensure that matters such as bedding receive regular checks and cleaning/changing takes place as necessary. One bathroom evidenced that staff had not put the toothbrushes back in the specified service users beakers staff must be mindful of this in order to reduce the risk of cross infection. This was brought to the attention of the manager during the inspection. A requirement was made that members of staff follow the home’s policies and procedures regarding infection control. External – 1). Some work was required to keep the patio area clear of weeds and ensure that all the paving stones were flat and secure. 2). Parts of the external wall require work to make good as brickwork was exposed in some areas and in others the external covering was beginning to come away. 3). The guttering evidenced weed growth and needed clearing. 4). One fly screen in the kitchen had come away and could not be secured the screen required replacing. 5). Bathroom cabinets were provided with keys to keep them locked, all were open and contained chemicals hazardous to health. In general service users would not be able to reach inside the cabinets however staff must be in the habit of keeping them locked as prospective service users may be ambulant or have more physical movement available and be able to reach the contents. 6). Ramps had not been fitted to the balcony areas and a number of the wheelchairs are heavy to handle and access to all areas of the home by some service users may be problematic. Bathroom cabinets were provided with keys to keep them locked, all were open and contained chemicals hazardous to health. In general service users would not be able to reach inside the cabinets however staff must be in the habit of keeping them locked as prospective service users may be ambulant or have more physical movement available and be able to reach the contents. A requirement was made to ensure that members of staff follow the organisation’s policies and procedures regarding the storage of cleaning chemicals. Ramps had not been fitted to the balcony areas and a number of the wheelchairs are heavy to handle and access to all areas of the home by some service users may be problematic. A requirement was made to provide ramps in order to ensure that service users and members of staff are not put at risk by negotiating areas of the home with wheelchairs where ramps had not been provided. Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 22 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): 31,32,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further work is required to ensure that all the information required by The Care Homes Regulations 2001 about members of staff is provided. A central training plan has not been completed making it possible for members of staff to miss mandatory training. Staff supervision had not been carried out regularly and may affect outcomes for staff regarding training and development needs. EVIDENCE: A number of personnel files were sampled and were found to be in good order generally. Where members of staff had been working at the home for some time photographic ID had not provided nor were recent photos available. A requirement was made to ensure that all the staff files meet the current The Care Homes Regulations 2001. Job descriptions were not placed in the files although employment contracts were provided to all those sampled. A requirement was made to ensure that all staff has a copy of their job description on file. Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 23 All those sampled had been appraised using the organisation’s document however supervision had not been provided on a regular basis, which is required and would underpin the appraisal process. Individual training records are kept and access to training was not seen as a problem by staff or the manager. A requirement is made to ensure a central record of training is available at the home to ensure that staff do not miss any mandatory courses particularly refresher training. For example when checking one member of staff’s file the manager noted they were due for their entire mandatory training in August 2006. All those sampled that required work permits were checked and correct. The home would find it useful to have a separate record of when work permits are coming to an end in order to ensure action is taken early and members of staff supply the necessary documentation to confirm their continued right to work in the UK. The organisation’s HR department holds the records. The home keeps a copy of the central record of Criminal Record Bureau (CRB) checks and these files were sampled against the list provided and all staff had a current CRB. This matter was also confirmed in discussion with a new employee who stated now they had their CRB they ‘could do the job in full’. The home recruits physio assistants who are trained by the organisation’s physio to provide for day-to-day needs of service users. Domestic staff had been recruited although care staff were seen assisting with cleaning during the inspection for example mopping the dining room floors etc. A chef had been employed to ensure care staff could concentrate on service users needs and that food could be cooked from fresh and the overall health and safety needs regarding the preparation of food could be met consistently for example the recording of core food temperatures/fridge and freezer temperatures/stock control/cleaning of the kitchen area and quality auditing of provisions when they arrive. Thirty eight (38) members of staff work at the home of whom six (6) are qualified nurses and eighteen (18) are care staff. Nine (9) of the care staff are qualified to NVQ level 2 or above including those who qualifications gained abroad have bee confirmed as equivalent to NVQ 2 or higher. Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further work is required to ensure the home and the organisation takes all the action necessary to safeguard service users. The requirement that policies and procedures are reviewed had not been met and this may lead to confusion as to what action to take should a safeguarding/adult protection concern be raised within the service. Health and safety within the home with regard to regular checks on aids, adaptations and equipment was well considered EVIDENCE: The manager is nurse qualified and had completed the registered managers award. As stated previously a number of the organisations policies and procedures require review in order to safeguard service users. Record keeping has continued to improve as noted in the section on care plans/activities they are clearer and easier to access. Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 25 Health and safety checks looked at were up to date apart from swimming pool test evidence examined showed that this had last been carried out in 2004. The fire risk assessment seen by the CSCI was also dated 2004 a requirement was made to seek confirmation as to how often a fire risk assessment must be completed and to complete a further fire risk assessment should it be necessary. Issues that arose re safeguarding/protecting adults are organisational were not within the remit of the manager of the home however it affects the overall rating of the home as the matter is related to safeguarding service users. The manager reported that the organisation was revising the quality assurance process but was unaware of the exact details of progress to date. The quality assurance audit will include all aspects of the running of the home. A requirement was made for the organisation to ensure that service users and or their representatives’ views on the running of the home are sought as part of any quality assurance process and how will they make public the information gained. Doors to the boiler room and another electrical machinery cupboard were unlocked, some bathroom cabinets were unlocked and contained chemicals hazardous to health and the w.c used by staff was also unlocked and contained chemical a cleaner. It was recognised that most of the current service users are unable to access those areas however the home must be in the habit of ensuring these areas are locked and that all chemicals are locked away to further reduce the risks to service users. Members of staff must be careful to ensure that toothbrushes are kept separate and in the holder belonging to the named service user in order to reduce the risk of cross infection. This matter has previously required attention and staff must remain mindful of such issues. A number of respondents stated that they had no knowledge of the CSCI, their role or that inspection reports were available. A requirement was made that the home review how information regarding the complaint procedure and inspection reports and brought to the attention of relatives, visitors and others who attend the home. Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 X 5 2 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 2 32 3 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 27 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 2 Standard YA1 YA5 Regulation 4 Requirement Timescale for action 11/08/06 31/07/06 3 YA7 4 YA9 5 YA13 6 YA20 The registered persons must review and update the statement of purpose. 5(1)(b)(c) The registered persons must ensure that each service user is provided with a statement of terms and conditions. Timescale of 31/12/05 not met. 15(1)(2)(a)(b) The registered persons must (c)(d) ensure that the care plans are reviewed and updated and that such reviews are carried out consistently. 13(4) The registered persons must ensure all risk assessments are reviewed and updated and ensure that such reviews are carried out consistently. 12(4)(b) The registered persons must carry out a review of the service users to ensure their cultural, religious are met. The outcomes must de documented and recorded. 13(2) The registered persons must review the arrangements for the recording, handling, safe keeping, safe administration and disposal of medications. DS0000017623.V300875.R01.S.doc 31/07/06 31/07/06 11/08/06 14/07/06 Melbreck Version 5.2 Page 28 7 YA22 22 8 YA23 13(6) 9 YA24 23 10 YA31 18(1)(a) 11 YA34 19(1)(b) 12 YA35 17(2),18(2) 13 YA36 18(2)(a) The registered persons must review the complaints procedure and ensure that it fully meets The Care Regulations 2001. The registered person must ensure that the organisations protection of vulnerable adults policy and procedure are reviewed and meet Surrey County Councils multiagency procedures. Timescale of 31/12/05 not met. The registered persons must carry out a review of the work required internally and externally to the home as noted within this inspection report and provide the CSCI with a timescale for action. The registered persons must ensure that a copy of each members of staff job description is placed in their personnel file held at the home. The registered persons must ensure that all the staff personnel files held at the home contain all the requirements listed in Schedule 2 of The Care Homes Regulations 2001. The registered persons must ensure that a central training record is kept by the home to ensure that all members of staff receive the training required in a timely fashion. The registered person must review the dates for supervision to ensure they meet the standard of at least six sessions per year. Timescale of 31/12/05 not met. 31/07/06 31/07/06 11/08/06 31/07/06 11/08/06 11/08/06 31/07/06 Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 29 14 YA39 24 15 YA42 13(3) 16 YA22 YA42 13(6) 17 YA42 13(4) The registered person must provide the home with a copy of the proposed quality assurance audit procedure. The registered persons must ensure that toothbrushes are kept separate and in the named holders provided. The registered persons must review how information regarding complaints and inspection reports are brought to the attention of relatives, visitors and others who attend the home. The registered persons must ensure that all those areas of the home containing machinery and/or chemicals hazardous to health are locked and kept locked when not in immediate use. 31/07/06 08/07/06 31/08/06 08/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA7 YA13 Good Practice Recommendations It is recommended that the level of family involvement is recorded clearly on the front sheet of the service user’s files. It is recommended that the home ensure that members of staff complete all the documentation regarding the leisure activities of the service users. Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Melbreck DS0000017623.V300875.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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