Inspection on 11/05/07 for Mokattam

This inspection was carried out on 11th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mokattam 28/11/05

Mokattam 28/07/05

Mokattam 27/01/05

Mokattam 24/08/04

Mokattam 06/01/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Mokattam Altwood Bailey Maidenhead Berkshire SL6 4PQ Lead Inspector Stephen Webb Unannounced Inspection 11th May 2007 10:15 DS0000011293.V331566.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 DS0000011293.V331566.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. DS0000011293.V331566.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mokattam Address Altwood Bailey Maidenhead Berkshire SL6 4PQ 01628 626070 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) Turnstone Support Limited Louise Collins Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000011293.V331566.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th November 2005 Brief Description of the Service: Turnstone Support Ltd, an independent agency, is registered to provide personal care, support and accommodation in Mokattam for up to six younger adults who have learning disabilities. Mokattam is a large detached property situated in a quiet residential road on the outskirts of Maidenhead. There are local shops and facilities within walking distance and a large range of leisure and recreational centres in the local area. The house has a secluded rear garden that has seating, shade and room for leisure activities. There is limited off road car parking available at the front of the house where the residents’ transport vehicle is kept. The resident’s contribution to the care element of their fees was £62.35 per week at the time of inspection. DS0000011293.V331566.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit from 10.15am until 5.45pm on 11th of May 2007. This report also includes reference to documents completed and supplied by the home, and those examined during the course of the site visit. The report also draws from conversation with the senior carer, service manager and staff members on duty. Three of the residents, the manager and another staff member were away on client holidays. None of the three residents present for the inspection was able to communicate verbally with the inspector in terms of answering questions, so some time was spent observing interactions between residents and staff at various points during the inspection. One resident was unwell in bed. Written feedback forms were obtained from five residents, which had been completed with facilitation from staff or family. The inspector also toured the premises, and ate lunch with the residents. What the service does well: Prospective residents are provided with information about the service, to inform their decision about its appropriateness, and appropriate pre-admission assessment and transition planning is undertaken. The identified needs and wishes of residents are reflected in detailed care plans and other documents, which are held within the individual resident’s bedroom. Residents can attend college courses, and access a good range of in-house and community based activities. The home has an adapted vehicle with which to support community access. Contact with family is supported and encouraged by the staff, through visits, and letter and telephone. The rights of residents to make decisions and choices are maintained and supported very effectively, and some resident decisions are specifically recorded. They are encouraged to take part in the day-to-day operation of the home, whilst retaining the element of choice. DS0000011293.V331566.R01.S.doc Version 5.2 Page 6 Residents are involved in the production of the home’s menu, and specialist dietary needs are effectively supported. Residents’ health needs are also effectively met, with appropriate specialist consultation. Though residents were unable to comment directly about the complaints system, they did indicate that staff listened to their views, and records indicate they are consulted about many aspects of their daily lives. The provider has appropriate systems in place to protect residents from abuse, and staff have received training on these systems. The home provides a comfortable environment for residents, which is well maintained and homely. Some specialist adaptations and equipment were provided to meet individual needs. Standards of hygiene were good. The staff team is experienced and well trained for the most part, though numbers have recently been stretched by the departure of two staff, whose shifts are currently being covered via bank and agency staff. The provider’s recruitment and vetting procedure provides protection to residents, and residents are also included in the interview process. The views of residents and relevant others are sought as part of a quality assurance system, which the provider is seeking to develop further. The health, safety and welfare of residents are effectively promoted. What has improved since the last inspection? What they could do better: Staff should be reminded of the importance of appropriate medication recording, and consideration should be given to the establishment of a medication administration check as part of handover. The benefits of producing an adapted version of the complaints procedure to aid its explanation to residents should be considered. The potential benefits of additional specialist hoist equipment to one resident, should be investigated. DS0000011293.V331566.R01.S.doc Version 5.2 Page 7 The staff training records need to be improved by maintaining an accurate overall training profile reflecting the current position. The home’s accident recording system should be reviewed, and more detailed staff rotas should be retained, which include the names of any agency and bank staff. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000011293.V331566.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 DS0000011293.V331566.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs, wishes, likes and dislikes of prospective residents are identified and assessed, and they are provided with information about the service, in order to inform their decision about its appropriateness. EVIDENCE: Examination of the case records of two case-tracked residents indicated the presence of initial care management assessments as well as organisational pre-admission assessment documents for both residents, as well as transition planning documents relating to the appropriate pacing of transfers. The resident questionnaires returned by four residents, (completed with support from parents/others), indicated they had been provided with sufficient information about the service before moving in, and two confirmed they had been invited to visit before deciding on the home. DS0000011293.V331566.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The needs and wishes of residents are reflected in the detailed care plans and supporting documents, which are held within the individual’s bedroom. There is good evidence of decision-making and choice on the part of residents, with any necessary support being provided. Support is provided within an appropriate risk assessment framework. EVIDENCE: The files examined included detailed individual care plans as well as a range of other relevant documents containing supporting information and day-to-day details. DS0000011293.V331566.R01.S.doc Version 5.2 Page 11 These included activities plans, records of personal care, individual risk assessments, healthcare records, and behaviour management plans, where applicable. There were signature sheets confirming the involvement of the resident in various aspects of decision-making regarding their care, their holding of keys and retaining the responsibility for management of their own finances, as well as having seen their files. Individual’s case files are actually held within the resident’s bedroom so they have full access, though some support would be needed in most cases in the resident’s understanding of these. The files clearly indicate opportunities for decision-making by residents regarding their care and support, and their involvement in making a range of choices, including the identity of their key worker. There is also a specific record identifying any stated/indicated likes and dislikes, which was in pictorial form to facilitate understanding, where necessary. Review documents were present on file with appropriate frequency, indicating the involvement of relevant parties, including the resident themselves. A relative also confirmed her invitation to, and involvement in reviews. All of the residents retain management responsibility for their own personal allowance, with support provided as needed individually. Each has their own cash tin, which they hold, together with its key, and the balance is checked daily either by the resident themselves, or staff. Indications from records and discussions regarding residents’ monies suggest these are well managed. Evidence was present within files, of an appropriate and individualised risk assessment system, which does not unreasonably restrict residents’ opportunities. Observation during the inspection confirmed that residents were supported to make choices and decisions on a daily basis, and this was supported by the feedback from resident questionnaires and in conversation with a relative during the inspection. DS0000011293.V331566.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents have opportunities to attend college, are provided with a good range of in-house and community based activities, and can access local community facilities with staff support. The home has an adapted vehicle with which to support community access. Residents’ contact with family is supported and encouraged by the staff, through visits, and letter and telephone. The rights of residents to make decisions and choices are maintained and supported very effectively, and some decisions are specifically recorded. They are encouraged to take part in the day-to-day operation of the home, whilst retaining the element of choice. Residents are involved in the production of the home’s menu, and specialist dietary needs are effectively supported in consultation with appropriate external specialists. DS0000011293.V331566.R01.S.doc Version 5.2 Page 13 EVIDENCE: Residents’ case files contain a detailed individual activities programme, including activities within and outside the home and some domestic tasks, as well as any college attendance, and some periods show a range of alternatives from which the resident can choose on the day. Relevant individual risk assessments are in place where applicable. Three residents currently attend college part-time, and another has previously attended for a cookery course. Two were booked on another cookery course that was cancelled, and are priorities for the next time it is run. The actual activities attended are noted within the individual ‘record of activities’ sheets. Residents were noted to have exercised some choices about activities participation during the inspection, and one, who would normally have attended college, was unwell in bed. Residents have access to a variety of activities in the local community, including shopping, bowling, going for walks, visits to the pub and going to the cinema and leisure centre, as well as attendance at day services and college. The unit has a people carrier, which is adapted to carry one wheelchair user at a time, and at times the staff may use their own vehicles (with appropriate insurance), or the “People to Places” transport scheme. There were five drivers in the team at the time of inspection, able to drive the unit vehicle. Most of the residents also go on holiday, though needs of one individual have prevented this and she tends to have days out instead. One resident was on holiday in Spain with their family and two others were also in Spain with the unit manager and another staff member, at the time of the inspection. Two of the residents attend a local church sometimes on Sundays, though the others express no desire to do so. One attends a monthly church-run group. Levels of family contact are very good, with most having regular contact. Telephone contact is also maintained and supported, and next of kin are invited to reviews. If residents receive letters, they are supported to open them and can choose to have them read to them if they wish. One relative confirmed that she was very much happier with the care her daughter received in Mokattam, than in a previous placement, and said the DS0000011293.V331566.R01.S.doc Version 5.2 Page 14 unit was homely and “the staff take notice of the residents on a day-to-day basis, take them out and talk to them”. It was also noted that the staff take notice of what relatives suggest. Feedback from residents was also generally positive about the activities available and the availability of choice in these areas. Residents all have their own bedroom and front door keys and keys to their cash tins, though not all choose to use their bedroom and door keys. Residents are encouraged to be involved in aspects of the daily routines of the home as well as in their own care, laundry and room cleaning. One of the residents is fed via a feeding tube and has special feeds prepared, for which staff have received the necessary training. Another is on a special diet to build up their weight, following consultation with a dietician. The remaining residents choose the menu on a weekly basis via pictures to support them in making their choices, with each choosing a main meal, though an alternative is made available on the day if someone does not want the meal offered. One of the residents enjoys being involved in meal preparation and the others are encouraged to take part in this and the food shopping, as well as table laying etc. DS0000011293.V331566.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported with due regard for their needs and wishes, and their health needs are effectively met, with appropriate specialist consultation. None of the residents has opted to manage their own medication, and the home has a system in place, which effectively manages the medication on their behalf, for the most part. Staff need to be reminded of the importance of appropriate medication recording. EVIDENCE: As already noted, the preferences and wishes of residents are well documented where these are known. Staff showed a good awareness of the specific dietary support needs of two of the residents, and appropriate external advice and training had been sought from external professionals. DS0000011293.V331566.R01.S.doc Version 5.2 Page 16 Weight charts were being maintained where necessary, as were other individual records to address individual needs. Relevant risk assessments had been undertaken. Staff support the residents to encourage them to take part in the daily tasks in the home and take relevant decisions for themselves, with support if required, even extending to them having a say in the choice of their key worker. Healthcare records indicated appropriate access to external healthcare professionals. Residents are asked regarding self-medication and have signed for the staff to manage this on their behalf. Healthcare needs in general, are met effectively. Although some of the residents do not communicate verbally, they are able to make their views known via the use of Makaton or other methods, such as leading and facial expression. Staff have received some Makaton training and all are scheduled to receive more of this later in May. Residents were observed to be relaxed in their relationships with the staff on duty, and interactions between them were warm and positive. None of the residents manages their own medication and the home has a system in place to manage this on their behalf, which should provide the required medication audit trail. However, a number of gaps in administration recording were noted on the medication administration record, (MAR), sheets. Staff need to be reminded of the importance of these records, and it may be prudent to introduce a monitoring system to reduce the risk of future occurrences. DS0000011293.V331566.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Though residents were unable to comment directly about the complaints system, they did indicate that staff listened to their views, and records indicate they are consulted about many aspects of their daily lives. The benefits of an adapted version of the procedure to aid its explanation, should be considered. The provider has systems in place to protect residents from abuse, and staff have received training on these. EVIDENCE: The home has an appropriate written complaints procedure, which details the potential staff advocacy role in supporting a resident, who is unable to make a complaint directly, to make one. However, as yet no adapted version to aid explanation of the process to residents is available. The potential benefits of an adapted version of this procedure should be considered. Feedback from residents questionnaires, which had been completed with support, indicated that few were able to make complaints directly, but that most would be able to indicate they were unhappy about something, so an adapted version to help in explaining about complaints may be beneficial. DS0000011293.V331566.R01.S.doc Version 5.2 Page 18 The service does also seek the views of residents, their relatives and others, via the quality assurance system. The complaints log contained only one recent issue, concerning an area of the garden fence, which was awaiting resolution, based on identifying who is responsible for the boundary in question. The service has an appropriate procedure in place for the protection of vulnerable adults and the staff have all received POVA training, though it was not clear when this training was last updated for some, owing to the lack of an up-to-date training spreadsheet. The manager should review the dates of receipt of this training and prioritise updates where necessary. (Recommendation made under Standard 35 later in report). Systems for protecting the funds of residents are in place and each resident holds their own personal allowance. The resident signs for how the spare key is looked after/stored. The balance is also checked daily by the individual or with staff support. DS0000011293.V331566.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a comfortable environment, which is well maintained and homely. Specialist adaptations and equipment were provided to meet individual needs, though the potential benefits of additional items should be investigated. Standards of hygiene were observed to be high. EVIDENCE: The communal areas of the home are pleasantly decorated and furnished to maintain a homely environment, with various pictures and ornaments. The bedrooms seen were also decorated to a good standard and individualised to reflect the interests and needs of their occupant. DS0000011293.V331566.R01.S.doc Version 5.2 Page 20 The home has a combined staff office and sleep-in room, but this is equipped with a proper bed. Two of the residents use wheelchairs when outside the home, with one also using a wheelchair in the home. The other uses a walking frame indoors. The ground floor of the home has spacious rooms and corridors and the doorways are of a good width so as not to restrict their movements. Ramps are present at exit doors where there is a change of level. Both residents occupy ground floor bedrooms with en suite bathrooms. The attractive and secluded garden includes a level patio area and a large lawn bordered by a variety of trees and shrubs. One of the wheelchair using residents also has a hospital-type bed and a mobile hoist within the en suite bathroom to enable staff to support her to transfer to a shower trolley therein. Given her needs and the health and safety considerations for both the resident and staff, the home should consider, through consultation with an occupational therapist, the potential benefits of an overhead tracking system with an integral hoist to better facilitate her personal care. The standards of hygiene in the home were good. The home’s laundry was in an adjacent converted garage, and though the washing machine was not equipped with a sluice cycle, specialist laundry bags were in use to minimise handling of soiled items. Consideration should be given to the need for a washing machine equipped with a sluice cycle. DS0000011293.V331566.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a capable staff team, which has recently been stretched by two vacancies, and been supplemented via bank and agency staff. The Provider’s recruitment and vetting procedure provides protection to residents, who are also included in the interview process. Residents’ needs are met by an appropriately trained staff team, though training records need to be improved to accurately reflect the current position. EVIDENCE: Observations of staff during the inspection indicated a good understanding of supporting the residents on an individualised basis to meet their needs, and staff offered choices and encouraged participation. Feedback from relatives was positive regarding the staff, who were noted to pay attention to the individual residents and to meet their needs effectively. DS0000011293.V331566.R01.S.doc Version 5.2 Page 22 Two staff had left the unit since the previous December, (of only three leavers since the last inspection in November 2005), and there had been a resulting increase in the use of in-house bank staff and known agency staff, recently to support shifts. However, the rotas were not an accurate reflection of this position since they did not include the hours of bank and agency staff, which were listed on separate time sheets, nor did they include evidence of day-to-day shift changes for the most part. An accurate record of which staff worked on every shift is required to be kept, and this is most easily maintained via a rota, which includes all permanent, agency and bank staff. The manager should address this matter. (Requirement made under Standard 41 below). The standard staffing for the unit is three staff throughout the waking day with one staff sleeping in and a further waking night staff each night. This is sufficient to meet the current needs of the residents. Six of the nine permanent staff have attained their NVQ to at least level 2, and one is a registered nurse. The staff had received Makaton training, to support communication with four of the residents, and this was due to be updated later in May. Staff had also all received certificated specialist training to enable them to manage the specialist dietary needs of one resident. However, because the overall training spreadsheet was not up-to-date, the most recent dates for some training were not readily available without recourse to the individual training records for each staff member. This was particularly noted for the training on the protection of vulnerable adults, which was shown as being last provided several years ago for some staff, though the service manager thought they would have received subsequent updates. There were also implied gaps in first aid and fire safety training, based on this record. The collective training spreadsheet should be brought up to date and should be maintained as such, as a record of the current core-training status of the team as part of preparing a training-needs analysis for the unit. Examination of the recruitment records for the two most recent recruits indicated an appropriately rigorous recruitment and vetting process for potential new staff, which includes a second interview by residents, supported by staff in the home. This is good practice. The recruitment records included a detailed induction checklist and workbook, which were signed and dated. DS0000011293.V331566.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, 41 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a well-run service, with a competent permanent manager and a core of long-term staff. The views of residents and relevant others are sought as part of a quality assurance system, and the provider is developing a more unified system leading to a continuous improvement plan for ongoing service development. The rights and interests of the residents, are safeguarded by the majority of the unit’s systems and recording, but the accident recording system should be reviewed, and staff rotas should be retained, which are an accurate record of all of the staff who were on duty, including named agency and bank staff The health, safety and welfare of residents are effectively promoted by the service. DS0000011293.V331566.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager is undertaking her Registered Manager’s Award having been manager for about nine months, (senior for about a year previously), and had been registered in April 2007. She was absent on a client holiday on the day of inspection, but there was evidence of some effective management systems, including consultation with residents, and staff had clear guidelines and systems within which to work. A set of detailed policies and procedures produced by the provider are also available in the home. The service manager came to the unit to support part of the inspection and discuss some of the management aspects. A cycle of quality assurance questionnaires had been undertaken recently, with residents, and separate surveys of relatives and staff views had also been distributed. These generate separate summary reports from which separate action plans then arise. The service manager described a new system based on a continuous improvement plan, which will incorporate input from the various relevant sources, also including complaints and inspection. It is proposed that the provider’s Policy Review Group will review these overall plans as well as them being monitored monthly as part of the manager’s supervision. As long as there is evidence of ongoing development planning and records of achievement of the goals and targets are maintained and updated, this should be an effective way to meet requirements and generate ongoing unit development. The provider undertakes regular Regulation 26 monitoring visits and copies of reports were on file in the home. The format is detailed, and performance is scored against the national minimum standards. As noted earlier in the report an accurate record of which staff worked on every shift is required to be kept, and this is most easily maintained via a rota, which includes all permanent, agency and bank staff. The manager should address this matter. It is notable that in this unit the residents’ care plans etc. are retained within their bedroom, and they are actively encouraged to be involved in maintaining some aspects such as their financial records. Examination of a sample of health and safety-related service records indicated regular servicing and maintenance. DS0000011293.V331566.R01.S.doc Version 5.2 Page 25 Individual fire evacuation plans were in place and this was in pictorial form, for one resident. Fire drills are held monthly and the alarm system is tested weekly. A unit fire risk assessment was in place, which was last reviewed in November 2006, following a fire safety audit. Various individual risk assessments were in place to support residents in aspects of daily life and activities, some of which included clear evidence of resident consultation and involvement. Accident recording was being done within a single tear-off pad for both residents and staff. It is suggested that separate pads be used to enable easier monitoring of the continuity of the serial numbers thereon. At present each completed accident form goes to the service manager and once returned is filed in a collective accident record. No record remains in the unit until the form’s return (aside from the stub on the accident form pad, which contains no information). Also no record of the accident is made within the resident’s case file. In order to address records requirements it is recommended that the current accident recording system be reviewed. If the accident form is photocopied on initial completion and copies are filed in the collective accident record and the individual resident’s case record, the original can then be sent to the service manager, without the details being absent from unit records. This would meet requirements without generating significant additional work. It was also noted after investigation with the service manager that one accident form could not be accounted for within the existing system. The manager should investigate the whereabouts of this form. DS0000011293.V331566.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 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 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 2 X 3 X 4 X 2 2 X DS0000011293.V331566.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO 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 YA41 Regulation 17(2) & Schedule 4.7 Requirement The manager must ensure that an accurate staff roster is retained, which details all of the staff who have worked in the home, including the names of any agency or bank staff. The manager/provider must review the accident recording procedure to ensure that the required records of accidents to residents are present in the home at all times. Timescale for action 11/06/07 2 YA42 17(1)(a)& Schedule 3.3(j) & 17(2) & Schedule 4.12(a) 11/06/07 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 YA20 Good Practice Recommendations The manager should ensure that staff are diligent in recording any medication given, within the MAR sheets, and should consider the implementation of a checking system for the MAR sheets, to ensure any errors or omissions are picked up promptly. The manager should consider the benefits to residents, of providing an adapted version of the complaints procedure. DS0000011293.V331566.R01.S.doc Version 5.2 Page 28 2 YA22 3 YA24 4 YA35 The provider should consider the benefits to the resident and staff, of providing an overhead tracking hoist system between one resident’s bedroom and their en suite bathroom. The manager should maintain an accurate training profile for the staff team as part of the training needs analysis. DS0000011293.V331566.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000011293.V331566.R01.S.doc Version 5.2 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. 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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