Inspection on 24/07/07 for National Autistic Society (Gillitts Road)

This inspection was carried out on 24th July 2007.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

National Autistic Society... 12/03/07

National Autistic Society... 20/11/06

National Autistic Society... 17/08/05

National Autistic Society... 25/04/05

National Autistic Society... 26/08/04

National Autistic Society... 17/06/04

Similar services:

Hillside

Applegarth

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Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 National Autistic Society (Gillitts Road) Gillitts Road Wellingborough Northants NN8 2HX Lead Inspector Sarah Jenkins Unannounced Inspection 24th July 2007 07:20 National Autistic Society (Gillitts Road) DS0000012863.V341239.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 National Autistic Society (Gillitts Road) DS0000012863.V341239.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. National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service National Autistic Society (Gillitts Road) Address Gillitts Road Wellingborough Northants NN8 2HX 01933 275525 01933 275524 kevin.bacon@nas.org.uk 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) The National Autistic Society Position Vacant Care Home 12 Category(ies) of Learning disability (12) registration, with number of places National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. All service users have a diagnosis of an Autistic Spectrum Disorder The home may only admit service users aged 18-45 The total number of service users must not exceed twelve Date of last inspection 12th March 2007 Brief Description of the Service: Gillitts Road Project is a home run by the National Autistic Society. It is situated approximately a mile from Wellingborough Town Centre, with easy access to local community facilities and services. The Unit has two purpose built and self-contained five bed houses, and a self contained “flat” with two beds, all within the same building but with separate entrances. There are pleasant enclosed garden areas. Service user bedrooms are all single rooms; there is no lift at the home. The Home admits people with Autistic Spectrum Disorders and related conditions who have a high level of dependency, and in one of the houses, service users also often suffer from behaviour that is challenging to staff. Weekly fees were set at 1766.65 in March and are mainly inclusive although there are additional charges for some health care aids, and some extra charges when holidays are taken with the home. Details about the home in the form of a Statement of Purpose and Service Users Guide can be obtained from the Registered person at the home or through the National Autistic Society. National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for Service Users and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting two service users and tracking their care through meeting with the service user, a review of their records, discussions with the care staff and observation of care practices. The Inspector visited during the early morning, in order to observe the morning routines in the “Green House” and meet with staff, including one of those on night duty. The inspection site visit at the home was undertaken over a period of 7 hours. Service users have Autistic spectrum disorders and thereby communication difficulties. Establishing their choices and informed decisions is dependant to a large extent upon observations of their apparent satisfaction with their daily routines and the quality of their interactions and communication with staff. The inspection was conducted with the assistance of the newly appointed Acting Manager and other senior staff from the organization including the Responsible Individual. An application for the post of Registered Manager is expected shortly. The Annual Quality Assurance Assessment was submitted in July and feedback forms to relatives have been prompted, but none had been received back by the time of the inspection. What the service does well: Staff were observed to be alert and responsive to service users perceived needs and there was a high commitment amongst them to provide a full and caring service to residents. The National Autistic Society has responded promptly to the seriousness of the concerns that were identified at previous inspections and have rectified the specific urgent matters that were drawn to their attention at that time through the inspection process. There is recognition from the organization that there is still some way to go to fully meet all the National Minimum Standards, and a commitment to completing the improvement process. National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Outcome areas that must be prioritized for ongoing improvement are service users healthcare and the retention of a properly qualified and experienced staff team. Without proper attention to these two key areas there continues to be a danger that service users needs are met erratically, with variable quality, or poorly. Some standards under both these areas (Healthcare, Staffing) have been identified as problematic in recent reports, and various associated requirements have been made previously. It is disappointing therefore that improvements have not always been maintained, lasting or in some individual standards, sufficient. However, given the amount of work required, as identified in the inspection in March 2007; the prompt response made by the National Autistic Society; and the evidence of progress being made; further time is being given for these areas. There must be a continued commitment by the National Autistic Society of time and resources in order to satisfactorily resolve these issues. The records systems at the home do not always function for the designed purpose, i.e. to protect service users and enhance the quality of care. In parts records are cumbersome and ineffective, and staff are not supported through easy access to relevant information. Staff do not always maintain records in a manner that allows management staff to “track” progress on an issue and the Inspector was therefore unable to “unravel” some issues that arose in the course of the inspection, e.g. the administration of an essential medication, or the input to a service user on a healthcare problem. Quality Audit processes need to be more focussed on the actual outcomes for service users and the delivery of care. Some systems need to be refined and National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 7 workable for management and staff, e.g. staff training profiles kept on site, the implementation and maintenance of accurate medication profiles. There needs to be a high input of support and supervision for staff during this time of change, staff morale was mixed. The Acting Manager and Responsible Individual were advised of the inspectors judgement that the history of difficulties at the home, and the lack of strong leadership until recent months has led to a level of distrust of the organization by its own staff and service users/relatives at the home. Good communication routes need to be reestablished with relatives and advocates. There is a lot of work still to be done. 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. National Autistic Society (Gillitts Road) DS0000012863.V341239.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 National Autistic Society (Gillitts Road) DS0000012863.V341239.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): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users have a comprehensive assessment of their autistic spectrum needs and a planned but flexible transition period in accordance with these needs. EVIDENCE: The admission of a new service user was reviewed, and the pre-admission information gathered on the prospective service user by staff was mainly good. The transition arrangements were recorded and showed suitable arrangements had been made with proper consideration of the service users needs. The recording and accessibility of information for staff, showed less clarity and it was difficult both for the Inspector and a staff member to access relevant information easily. Care should be taken to ensure service users physical and healthcare needs are fully explored prior to their admission, through for example the completion of a nutritional assessment and advice from a dietician if issues are identified. National Autistic Society (Gillitts Road) DS0000012863.V341239.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): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff show that they are generally aware of service users individual needs and wishes, but access to relevant information needs to be improved to ensure the necessary consistency of care and thereby good outcomes for service users. EVIDENCE: There was a calm atmosphere observed at the time of the inspection. Service users appeared to be being appropriately supported in their daily routines. Staff reported that the quality of service users lives continues to improve and there was evidence of the introduction of a more structured approach through the gradual implementation of the TEACCH system (Treatment and Education of Autistic and Related Communication Handicapped Children). Advocacy is also being introduced and should thereby contribute to increased focus on service users choices and decisions in the future. National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 11 Although care plans are generally full and comprehensive, the important relevant information therein is not easily accessible to staff. The Acting Manager has identified the issue of excess information in the individual offices and ideas were discussed for refining information and enabling access. With the level of agency staff employed, it remains essential that information is easily accessible to secure a good quality of care and to properly manage risk areas. Risk was also discussed in relation to the staffing issues identified elsewhere on this report. National Autistic Society (Gillitts Road) DS0000012863.V341239.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): 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. Service users have active and fulfilling lifestyles, their needs for activity and relaxation are recognized and responded to. The full implementation of the TEACCH system (Treatment and Education of Autistic and Related Communication Handicapped Children) is likely to enhance the structure and quality of their activity programmes. EVIDENCE: Records were indicative of the active and satisfying lifestyles provided to service users. Staff confirmed that service users enjoyed their activities and daily lives. The introduction of TEACCH system (Treatment and Education of Autistic and Related Communication Handicapped Children) is being progressed and should add to the quality and consistency of the care delivery to service users including their security in the routines that they have chosen. Individual care plans show the detail of service users interests and evidence National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 13 that the home works hard towards providing appropriate enjoyable activities and some community based outings. Meals and menus were discussed with the Acting Manager and with staff who confirmed that service users eat a varied and appetizing diet. Menus were not reviewed at this inspection. Service users were observed to have breakfasts of their choice and these were presented to them at a time and in a manner that they preferred. Advice was given on the need to be alert to service users individual and specific nutritional needs where specialist needs are identified, and to seek the advice of dieticians where necessary regarding supplements and the presentation of a liquefied diet. Staff who spoke with the inspector at the time of the inspection felt that service users lifestyles were good and that they were enabled to undertake a range of suitable activities. National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 14 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): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements have been made since the last inspection and whilst the outcomes to service users are generally adequate, this outcome area has not been sufficiently improved since the last inspection to secure proper responses to all service users needs at all times. EVIDENCE: There was some evidence of staff’s observational skills and alertness to service users needs both in discussion with staff members, in observations of their practice and in daily logs and care plans. However, service users healthcare records do not always evidence secure systems to ensure their individual healthcare needs are consistently and sufficiently promptly responded to, or that managerial staff are able to track responses. For example an issue concerning service users nutritional and digestive issues did not appear to have been fully assessed or responded to. There was a lack of knowledge or evidence of the doctors’ advice regarding this service user although a new prescription had been issued indicating that contact had been recently made with the General Practitioner. National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 15 The issue of shortfalls in the overview and management of service users healthcare has been identified as a problem at previous inspections. Although some staff assured the inspector that they felt response to service users personal and healthcare needs was good, and the Inspector saw that service users appeared well presented, the Inspector was unable to evidence good healthcare for one service user in discussion with senior staff or through records. Good recognition and response to service users healthcare needs is of critical importance for this client group, given that service users are generally unable to understand, inform others or clearly express or promote their own health and welfare needs. The management and overview of the medication system continues to be improved. Professional advice has been sought and responded to and the Responsible Individual assured the Inspector that he had personally checked the system for two months and found it to be working correctly. However shortfalls were identified at the inspection, in areas where previous problems have arisen, i.e. the re-ordering and availability of drugs. None of the senior staff present at the time of the inspection were able to evidence whether a service user had recently missed an essential medication or whether the issue had been resolved in time. Advice was also given both at this and at the previous inspection for directions on Medication Administration Sheets. There has been a change in the contracted pharmacist since the last inspection and it is hoped that this issue will be resolved quickly. Medication profiles remain inadequate for the purpose for which they are designed, and advice was given on the need to implement secure recording systems. This outcome area should be prioritized for improvement. National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 16 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): 22,23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The good leadership in relation to this outcome area, and the evidence that staff are being made aware of the nuances of protection is improving outcomes for service users. EVIDENCE: The new Acting Manager has a good understanding of the process and wide nature of safeguarding and is taking the need for better staff understanding seriously. There is evidence that the Acting Manager responded promptly and appropriately to poor practice by an agency staff member, and service users are generally being effectively safeguarded. (See also Staffing) The service has had two complaints raised since the last inspection, and further issues about the management of the opening of the new section of the home were forwarded to the Northamptonshire County Council and the Commission for Social Care Inspection for information but do not appear to have been passed back to the Registered Person. The Inspector and the Responsible Individual discussed the need for building an improved trusting relationship between the home and the service users representatives. The recent history of difficulties appears to have led to loss of confidence by relatives and carers that the organization will hear and respond properly to their concerns or complaints. National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 17 Complaints received have been investigated under the homes procedures and it is understood that responses have been sent to the complainants. National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The quality of the environment has been improved dramatically since the last inspection and now provides a homely comfortable environment, which has benefited service users. EVIDENCE: The National Autistic Society has responded promptly and properly to issues of concern about the environment identified at the last inspection. The premises have been upgraded throughout, and the homes Acting Manager together with the Health and Safety officer have made competent decisions as to how secure Health and Safety systems and to meet service users needs. They have ensured that the provision of space, furniture and fittings is appropriate, safe and sufficiently robust to withstand any damage. Service users were seen to be enjoying the communal areas of the home and their bedrooms were more homely. Staff reported less damage by service users National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 19 lately and this may be as a consequence of a more considered and pleasing environment. The Inspector met with the Health and Safety officer and reviewed some records. A tour of some parts of the home was also conducted and no shortfalls were identified, that were not already being properly actioned (e.g. provision of suitably robust blinds/garden furniture etc). The inspector commends the work and resources that have gone into providing the quality of the premises. National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32.34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Daytime staffing at the time of the inspection was seen to be satisfactory but there was evidence that not all shifts are staffed with sufficient trained experienced staff. Good outcomes for service users are likely therefore to be variable. EVIDENCE: The day staff on duty at the time of the inspection showed themselves to be caring and competent, and the staff team as a whole had sufficient training and experience to offer good outcomes for service users. Numbers of day time staff on duty at the time of the inspection appeared adequate to meet service users needs at the time of the inspection. The levels and adequacy of the night staffing arrangements are currently under review by the management of the home. Advice was given that the vulnerability and known behaviours of service users, the training and experience of staff and the layout of the building must be fully taken into National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 21 account and risk assessed when considering staffing levels to ensure safe practice. The Inspector reviewed the rota cover for a recent weekend and was unable to ascertain the adequacy of the numbers of trained and experienced staff on duty. Advice was given to the Responsible Individual about the Inspectors concerns relating to the use of two agency staff to solely cover the “Beige House”, with back up from an able and experienced but not designated senior staff member working in the “Green House” during an identified shift. It was not possible to fully review staff training through the matrix provided, and it appeared that the person drawing up the rota was also unable to be confident in the training levels of staff teams on duty. Staff files did not contain documentary evidence of staff qualifications and training. Full information on agency staff was not available. The supervision of staff has been improved. The process remains under review, and advice was given on the need (already recognized by the Acting Manager) to re-establish staff trust in the leadership of the home. The recruitment process for staff remains professional, although advice was given on the homes responsibilities regarding the employment of staff through agencies. Although the Inspector was assured that staff turnover levels have slowed down recently, retaining a suitably experienced and qualified staff team has been problematic in the past, and from the evidence of the rota, the issue has clearly not yet been properly resolved. The reasons for staff turnover should be identified, recognized and addressed. Due to service users autistic spectrum disorders they have an intrinsic need to have familiar routines and the apparent degree of variation in staffing is not conducive to best practice. National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. 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. The management of the home has improved since the implementation of the agreed action on the improvement plan dated 19th March. Concerns raised at that time have been taken seriously and adequately responded to by the organization from Director level downwards. EVIDENCE: As details on outcomes for service users are reflected throughout the report and there is no Registered Manager, the judgement on the management of the home is based on the overarching management of the home by the organization. National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 23 A new Acting Manager has been appointed. A new senior staff member has also been recruited to deputize. The National Autistic Society has provided additional management support and finance to the Acting Manager to support positive change. The environment of the home now fully meets the Standards inspected, but there is still some way to go to implement sufficient improvement in some other outcome areas. Healthcare and Staffing should be prioritized, together with general management issues such as quality audit of the delivery of care to service users, and record keeping. Until these shortfalls are fully resolved service users will not have the full benefit of a well run home. Health and Safety issues have been properly addressed and there appears to be a competent understanding by the Health and Safety manager of the issues and responsibilities of this role. Information on the effect of the day-to-day operation of the management of the home is reflected throughout this report. Whilst management has been greatly improved, some of the shortfalls identified on previous reports have not been resolved, or sufficiently resolved to comply fully with the National Minimum Standards. Quality Audit of the actual outcomes for service users still needs to be properly overviewed. National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 2 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 2 x 2 x 2 x x 3 x National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA19 Regulation 13 Requirement Service users healthcare needs must be assessed and recognized, and responded to promptly and appropriately to protect their welfare. Staff, including agency staff must have the competencies and qualities required to meet service users’ needs Medication must be administered and recorded as administered in line with the General Practitioners instructions to meet service users health needs. Carried forward from last inspection as not met Timescale for action 30/08/07 2 YA32 18 30/08/07 3. YA20 13 30/08/07 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 YA2 Good Practice Recommendations Preadmission assessments should include detailed DS0000012863.V341239.R01.S.doc Version 5.2 Page 26 National Autistic Society (Gillitts Road) 2 3. YA6 YA19 4 YA20 5 6. YA20 YA20 7. YA23 8 YA34 9. YA35 10 YA37 assessment of all relevant areas of care need and include specialist input as required. e.g. nutritional assessments/dieticians input Staff should have easy access to all relevant information on service users care plans Records should properly evidence that service users healthcare needs are being fully met. It should be possible to track the response and the dates of the response to service users identified healthcare needs. (Issue carried forward from last inspection) The Royal Pharmaceutical Society guidance on the administration of medicines in Care Homes should be accessed to ensure all the processes in the home are compliant. Medication profiles for each service user should be properly set up and maintained. The management of the home must demonstrate that staff deemed to be trained and experienced to deal with medication matters, are undertaking their duties responsibly and effectively. Staff training and supervision needs should continue to be fully monitored and responded to, to ensure service users are receiving high quality professional care and responses from staff. The recruitment of staff should fully protect service users. Checks should be implemented to ensure that the employment of any persons on a temporary basis at the care home (e.g. agency staff) does not prevent service users from receiving such continuity of care as is reasonable to meet their needs. A full and up to date matrix of training required or due for renewal in relation to individual staff should be developed to enhance the management of rotas, necessary training for staff and to ensure National Minimum Standards are not breeched. The Management of the home needs to be secured through the registration of a Manager; and the appointment of sufficient suitably experienced senior staff to support management during the ongoing process of change and development. National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 National Autistic Society (Gillitts Road) DS0000012863.V341239.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!