Inspection on 24/01/06 for Pershore Short Term Breaks Service

This inspection was carried out on 24th January 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pershore Short Term Breaks... 19/09/07

Pershore Short Term Breaks... 25/09/06

Pershore Short Term Breaks... 08/03/05

Pershore Short Term Breaks... 08/09/04

Pershore Short Term Breaks... 09/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Pershore Short Term Breaks Service 48 Station Road Pershore Worcs WR10 1PD Lead Inspector P Wells Unannounced Inspection 24 & 26 January 2006 16:00 th th Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pershore Short Term Breaks Service Address 48 Station Road Pershore Worcs WR10 1PD 01386 552978 01386 553018 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) Worcestershire County Council Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate people for short-term care only. Date of last inspection 21st August 2005 Brief Description of the Service: The home is situated on a service road, off the main A1041, in a pleasant residential area approximately one mile from Pershore town centre. The home is situated at the end of a building shared with a day centre and provides a short-term respite care service. The home is operated by Worcestershire County Council and the responsible individual is Stephen Chandler. A new manager, Mrs Dee Edwins commenced in November 2005. The main entrance to the home and car park are shared with the staff and users of the day centre. The home has its own front door and apart from the joint use of a bathroom and the garden, the accommodation is self-contained. All the accommodation used by service users is on the ground floor with staff facilities on the first floor. The home can accommodate a maximum of five service users at any particular time for short periods of care. All the people who use the service have learning and physical disabilities. The aim of the home is to offer a service based on the principles of dignity and respect in a safe, warm and friendly environment. Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine, unannounced inspection that took place during the late afternoon of 24th January 2005. For this inspection, time was spent preparing, reading the monthly reports from the Service Manager and 4.5 hours were spent at the home. As the manager was off duty, a second visit was arranged to meet with the new manager, Mrs Dee Edwins. Also a new service manager, Ms Amanda Nally commenced in December 2005. This report to be read alongside the previous report of visits to the home earlier in the year. At the time of the inspection 11 service users, aged between 18 and 65 years, were being provided with planned respite stays - overnight in the week and at week-ends. Day care is not routinely provided during the week. On this occasion four service users were staying. Time was spent with the service users and staff. The inspector appreciated the co-operation of the service users, manager and staff. Whilst writing this report, CSCI has been advised that the manager was transferring to another Social Services care home. This was disappointing but the service manager has assured CSCI that there will be interim management arrangements until such time as another full-time manager is appointed. What the service does well: This established service provides care and support to 11 service users for planned short stays to give their families a break. The house is kept bright, clean and safe with a welcoming atmosphere. The service users appeared contented and comfortable. A service user whose stay was longer than usual, said this was okay because he knew the staff, they would look after him and take him out. The service users are supported by an experienced staff team who know the service users well. Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,5 The home has suitable information about the service for prospective service users and their families but it should be updated. The agreement needs to be introduced. EVIDENCE: There had been no new admissions since the last inspection therefore standards 2-4 were not fully assessed. The home has a suitable admission procedure and information to give prospective service users and their families. The statement of purpose and service user guide should be updated to reflect the changes in management. A draft agreement had been produced (contract/statement of terms and conditions) by another County Council home. The manager advised that it was being adapted for this respite service and will then need to be introduced to the service users and their families. Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Standards 6-9 were assessed and met at the last inspection. On this occasion the following was noted from the two service user plans and risk assessments viewed and discussed: The plans and risk assessments had been reviewed and were kept up to date. Additional guidance had been added when a service user’s needs had changed. For example – guidance for eating and a revised epilepsy protocol. The plan for a service user who was fairly new to the staff had been developed as staff got to know the person, their needs and preferences. It was pleasing to observe on this occasion how well this service user had settled and this was a credit to the staff. Service users were assisted positively and in a relaxed manner by staff in making decisions about their evening routine. This indicated that the standards were still being met. Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 10 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): 17 Service users are offered suitable meals and drinks. Some aspects of food preparation could be developed. EVIDENCE: These standards were assessed and met at the last inspection. On this occasion the following was observed which were indicators that these standards were still being met: The service users had all attended day placements during the day and some had been swimming so were tired. Hence a relaxing evening was planned. A service user who was staying for a few weeks was looking forward to being taken out to the pub by staff. There was music, videos and television to listen to/watch. A service user’s bedroom had colourful, flashing lights, which the person was known to like. Suppers were prepared individually according to the meals already taken that day and preferences. Two service users were having a meal prepared for them at the adjoining day centre, another was having a home-made vegetarian meal and the fourth soup with bread and butter. Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 11 As meals were being reheated, a temperature probe would be beneficial and the one in the home needed calibrating. Also as an additional precaution, hot drinks should be tested with a probe. A record could be kept on the service user plan as to the safe and suitable temperature each service user’s drinks and food should be served. If a member of staff could start the late afternoon shift in the week (staff commence at 4.00pm as service users are arriving which is a busy time), a little earlier, this would give time for more fresh, home-made meals to be prepared and cooked. Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 12 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): 20 There was a suitable medication system in place which should be reviewed to ensure that the safest method of administering service users’ medication is routinely used. EVIDENCE: Standards 18-19 were assessed and met at the last inspection. On this occasion the following was observed which were indicators that these standards were still being met: The personal and health care needs of the service users were clearly recorded in the service user plans. When the need of an individual changed the service ensured that any new guidance/protocol was obtained. The staff were monitoring service users with sensitive skin. The staff were attentive and respectful whilst transferring the service users. Each service user brought their own sling for use in the hoists. There was a variety of hoists and specialist chairs which the respite service were able to acsess from the adjoining day centre. Assistance with personal care was given in private and discreetly by one or two members of staff. Service users routines were known and respected. Service users were consulted about bathing or showering. Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 13 The Worcestershire Health Action Plans would be beneficial for service users to bring with them for their short stays and this has been raised with the service manager. Aspects of the medication had been inspected at the last visit. The previous requirement had been implemented – the manager and deputy advised that if the instructions were unclear regarding the administration of incoming medicines or it stated ‘as directed’, the service user’s GP is contacted for clarification prior to the medication being administered to a service user. On this occasion a medication round at suppertime was observed. It was said that some of the service users had their medication with their meal. Consideration should be given to administering medication in a safer manner to one service user at a time, directly from the original containers, at a separate time from serving the food and not in the kitchen. If medicines are being administered with food, the UKCC guidance on the covert administration of medicines (disguising medicine in food and drink) should be followed, as discussed with the manager. (This was not observed by the inspector who considered it would have been intrusive to sit-in at a mealtime with service users being assisted with their eating). Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The home had suitable policies and procedures in place for the protection of vulnerable adults. The staff ensure that service users are listened to and any problems that arise are addressed quickly. The method for managing service users’ personal monies could be developed. EVIDENCE: The home has a complaints procedure. It was apparent that a record was being kept of complaints received into the home, the investigation and outcome. The one complaint received since the last inspection was discussed with the manager. She agreed to check that the outcome had been actioned by the social worker and obtain a copy of the revised and agreed care plan. Complaints were being recorded in a book and a loose leaf file would be preferable to protect the confidentiality of the complainant and service user. The home had procedures in place for the protection of vulnerable adults. The service does not accommodate service users who may have challenging behaviour. The deputy had received training in protecting vulnerable adults from abuse and similar training for the staff has been requested from the Social Services. There were clear, communal records being kept when service users’ monies were managed by staff. The records need to be signed by staff involved in each transaction. Individaul records need to be kept for each service user’s stay with surplus monies being returned at the end of the stay. Service users should be supported in keeping their own monies in a lockable place in their bedroom, with staff assisting them. Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 15 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): 30 The ground floor of the home was homely, comfortable, clean, hygienic, safe and well maintained for the service users. EVIDENCE: The premises has previously been assessed and met these standards – see previous reports. There had been no changes to the home since the last visit and a maximum of four service users were being accommodated at any one time in single bedrooms. The fifth bedroom off the lounge continues to be appropriately used as a dining room. The ground floor of the home, where all the service users are accommodated, was warm, safe, clean and well maintained for the service users. The back garden had been improved by the ‘Friends of Pershore’ and there was now a lawn and decked area for service users to sit out and use in the summer. The garden had recently been viewed by the County Council’s health and safety officer and any recommendations made need to be addressed prior to the summer. At this visit the arrangements for hygiene and control of infection were assessed. The home has appropriate procedures in place and protective clothing for staff assisting with the personal care of service users. The laundry Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 16 is situated on the first floor and is suitably equipped. The home has separate staff bathing, toilet and hand washing facilities. In all the communal bathroom and toilets there were soap and paper towel dispensers. Staff had undertaken training in infection control. Consideration should be given to identifying one member of care staff on each shift to be responsible for the preparation meals and for protective clothing to be identified for staff working in the kitchen. There is a dishwasher. Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 Service users are supported by experienced, competent staff whom know the service users well. EVIDENCE: The service has a settled staff group who are experienced, trained and skilled to meet the individual needs of the service users whom they know well. The new manager and staff were getting to know each other, and to this effect the manager had re-introduced individual supervision sessions with each member of staff. Staff meetings were taking place monthly and minuted, also senior staff meetings. The training needs of the staff group and individuals was being reviewed by the manager. 40 of staff had an NVQ in care which does not meet the national minimum standard of 50 of staff having an NVQ in care. Staff also needed on going training opportunities to ensure their knowledge and skills were up to date. The manager advised that the County Council were reviewing the staffing arrangements and discussing proposals with the staff. It was said that consideration was going to be given to having sufficient staff on duty during the days at week-ends so that service users can be routinely taken out (previous recommendation) – most if the service users need 1:1 for going out. Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 18 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 The home has an experienced, manager. A quality assurance system needs to be introduced. The home has suitable systems in place to ensure the service users’ health and safety are protected. Staff are familiar with safe working practices. A few aspects of health and safety needed developing and refresher courses available for staff on a regular basis. EVIDENCE: The service had a new, experienced, qualified manager who had commenced in November 2005. She had eighteen years experience of working in residential care, the majority of this time working with service users who have a learning disability. Her application to apply to CSCI to be the registered manager was awaited, hence this standard could not be fully assessed. A quality assurance programme had not yet been introduced to the service by the County Council (previous requirement). However it was noted that there checks in place for health and safety matters. Also the new service manager had introduced annual audits of the service. Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 19 The standard of safe working practices was assessed and it was apparent that there were systems in place to ensure the health and safety of the service users and staff. Equipment, gas and electrical services were being checked regularly. Risk assessments for safe working practices and accident book were in place. The manager agreed to follow up on the legionella assessment which could not be located. The manager has since advised that the portable appliance testing, which was overdue, was completed on 15.02.06. Equipment is serviced through the adjoining day centre and the manager agreed to obtain copies of the service records so that these records could be in the home and available for inspection. Staff had received training in safe working practices but refresher courses in some aspects were needed. Five of the staff had undertaken first aid training. The home should aim at a member of staff trained in first aid being on duty at all times, preferably a first aider, as many of the service users who stay do have special needs (learning and physical disabilities); or a risk assessment carried out. The fire precautions were being regularly checked and a fire risk assessment was in place. Senior staff had undertaken the fire warden’s course in July 2005. A record was now being kept of the staff present at drills/in-house fire awareness training sessions. This should be recorded in a format which easily identifies that all staff have received quarterly fire awareness training. Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 20 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 X 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X 1 X X 2 X Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 21 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 YA5 YA20 Regulation 5 13 Requirement The draft agreement/contract must be introduced. (timescale of 31.12.05 not met) There must be a review of the procedure for administering service users’ medicines ensure the safest method is routinely used. A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standard 39. (timescale of 31.12.05 not met) Opportunites for on going training must be available for staff, in particular NVQs in care and safe working practices. A training programme must be submitted to CSCI. Timescale for action 31/03/06 28/02/06 3 YA39 24 30/04/06 4 YA42 13,18 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 22 1 2 3 4 YA1 YA17 YA19 YA20 5 YA23 6 YA42 The statement of purpose and service user guide should be updated by the new manager and copies sent to CSCI. Aspects of food preparation should be developed. Respite service users would benefit from having health action plans. A review should take place to ensure that medicines are not being adminsitered covertly to service users unless agreed (and recorded) by the service user, their next of kin and health care professionals. The records relating to the service users monies and complaints should be logged individually (rather than in one book) to respect the confidentiality of the service user and complainant. Service users should be supported in managing their own monies during their stays. The legionella assessmnet should be located and available for inspection. Pershore Short Term Breaks Service DS0000037468.V279896.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. 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