Inspection on 10/03/06 for Pfera Hall

This inspection was carried out on 10th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pfera Hall 16/12/08

Pfera Hall 27/11/07

Pfera Hall 05/12/06

Pfera Hall 22/06/06

Pfera Hall 22/08/05

Pfera Hall 23/03/05

Pfera Hall 02/09/04

Pfera Hall 16/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Pfera Hall Old Ledbury Road Redmarley Gloucestershire GL19 3JU Lead Inspector Mr Richard Leech Unannounced Inspection 10 , 13 & 14th March 2006 09:40 th th Pfera Hall DS0000016539.V286268.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 Pfera Hall DS0000016539.V286268.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. Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Pfera Hall Address Old Ledbury Road Redmarley Gloucestershire GL19 3JU 01531 650880 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) Stones Holdings Limited Mr Andrew John Biddlecombe Care Home 19 Category(ies) of Learning disability (19), Mental disorder, registration, with number excluding learning disability or dementia (19) of places Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd August 2005 Brief Description of the Service: Pfera Hall is registered to provide care with nursing for up to 19 service users with learning disabilities and mental health difficulties. It is near the village of Redmarley, between Ledbury and Gloucester. The home is set in substantial grounds and is surrounded by countryside. The home is divided into three units named Nimrod, Dorabella and Winston. Each has a lounge, kitchen, dining area and laundry as well as bathroom and toilet facilities. A separate wing houses the managers office, reception and day care facilities. The latter includes a gym, multi-sensory room, computers, training kitchen and art & craft centre. The home has several vehicles in order that service users can access facilities and amenities in the wider community. Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began on a Friday morning at around 10.00, lasting until mid afternoon. There were also visits on the following Monday (until mid afternoon) and Tuesday (until about midday). The manager assisted with the inspection. All three units were visited and service users and staff from each setting were spoken with. A range of records was looked at, including care plans, risk assessments, daily notes, correspondence, service users’ finances, training summaries and staffing files. Some external feedback was obtained from health and social care professionals who have involvement with the home, through comment cards and telephone contact. In future inspections it is planned to broaden the sources of external feedback further. What the service does well: What has improved since the last inspection? No requirements were made in the last report. No specific areas were identified as having improved since the last inspection, although the range of areas checked in the last visit was very limited. Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 6 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. Pfera Hall DS0000016539.V286268.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 Pfera Hall DS0000016539.V286268.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): 2 There is scope to improve the admissions process, which would help to ensure that service users’ needs can be met as fully as possible from the start of the placement. EVIDENCE: Admission/assessment material in respect of a person recently admitted to the home was checked. The file included basic details about the person, the referral, a history, care plans and notes from the previous setting, a social worker’s assessment and a summary of risk issues. A team member spoken with felt that they had received good information about meeting the person’s needs from the outset. There was an ongoing issue about the person’s psychiatric care. The person’s RMO (Responsible Medical Officer) had apparently not been made aware of the move to Pfera Hall, and had written to say that cover must now be provided locally. The person’s GP expressed some confusion about the situation in a letter, adding that there was no doubt that the person would require close supervision from a psychiatrist. The manager said that he had been informed by the person’s social worker that the same RMO would provide psychiatric input following the move to Pfera Hall. When it had been made clear that this would not be the case a referral had been made to the local Community Learning Disability Team, who had conducted an assessment and were making a decision about their role/input. Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 9 Whilst responsibility for the above issue clearly extends more widely that the home, it was agreed that, for future admissions, direct contact with the RMO should be made in order to fully clarify the situation as part of the admissions process. Regulation 14 (1) d requires that there be confirmation in writing to the service user that the home is suitable for meeting their needs in respect of health and welfare (so far as it is practicable to do so). The manager stated that this is not currently done. Such a document could include confirmation that issues such as RMO cover (where applicable) have been agreed. No needs assessment by staff at Pfera Hall was evident on the person’s file. The home should conduct its own thorough needs assessment (to include appropriate consideration of risk issues/management) in all cases to supplement external assessment material and as part of documenting the admission process and how decisions about admission are reached. The home’s Service Users Guide and Statement of Purpose include some information about admission criteria and procedures. The home also has an admissions policy. This includes reference to categories of registration, assessment of needs, introductory visits and a three-month trial period. The manager confirmed that service users are offered copies of the Statement of Purpose and Service Users Guide prior to admission, and that the terms and conditions document can be individualised. Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Care planning needs to be improved in order that the care plans form a comprehensive and up to date basis for support and intervention. Whilst choices are offered in many areas of day-to-day life, there are also significant restrictions on service users’ freedom and decision-making which are not appropriately documented and justified. Risk assessment in the home is poor and does not promote effective and consistent risk management. EVIDENCE: Care planning files for six service users were looked at. Three were checked in more detail. Whilst the care plans viewed covered appropriate areas, the following observations were made: • • Care plans began with the heading ‘problem’. This is very negative, and should be amended to use more positive language. Besides some care plans being signed there was little evidence of service users having significant input into the content of their care plans. For example, in conversation some service users expressed certain goals DS0000016539.V286268.R01.S.doc Version 5.1 Page 11 Pfera Hall • • • • • • • which were not reflected in their care plans. Staff said that they went through the care plans with service users, but the plans seen did not make any reference to this consultation. Some care plans included restrictions which appeared arbitrary or without robust justification. For example, one plans stated ‘due to winter hours he can ride his bike on Saturday and Sunday 10–12 and 2–4pm. This is so that it doesn’t interfere with mealtimes and it gets dark shortly after 4pm.’ This also indicates a lack of flexibility around routines, and an inadequate review system in that at the time of the inspection it was already light until 18.00. Staff reported that the person had not asked to use their bike. In most cases care plans provided only brief, quite general guidance and could not be said to fully describe how service users’ needs in respect of health and welfare are to be met (Regulation 15 (1)). For example, one person’s plan about communication gave just a few examples of what certain words and phrases usually meant. A plan entitled ‘working and playing’ stated that staff should ‘encourage choices and promote rights’ without saying what this meant and how it could be done. Plans around the management of agitation and challenging behaviour provided staff with very limited information in the form of a list with a few key points. Whilst in most cases there was evidence of regular review, where there had been a fundamental change this had not always resulted in the care plan being amended. This increases the risk that the original care plan will be followed by some staff who may miss a very significant review entry on the back of the form. For example, one person’s smoking care plan referred to being given cigarettes hourly and staff retaining the lighter. A review entry on the back said that the person now holds their cigarettes for the day and their lighter. In such cases the care plan itself needs to be fully updated. Another person’s plan referred to them accessing a local facility independently, which staff reported no longer happened, and to them paying for some activities that staff said were now covered by the service. Some care plans seen had no evidence of review since October 2005 or, in some cases, March 2004. Most care plans did not appear to offer any structured programmes for supporting people to develop their abilities in certain areas such as money management and independent living skills. Through discussion with staff it was evident that some such work takes place, but this was not adequately reflected in care planning. Many care plans appeared to be duplicated and could be combined. For example, one person had plans entitled ‘budget management’ and ‘guidance on money management’. The same person had separate plans entitled ‘absconding’ and ‘leaving the premises’. The scope of care planning was inadequate. Some service users did not have care plans covering areas such as social needs, physical and mental health and the management of challenging behaviour, when assessment and review material indicated that there were issues which required DS0000016539.V286268.R01.S.doc Version 5.1 Page 12 Pfera Hall support/intervention. One person had just four care plans giving brief guidance about mental and physical health, independence & outside interests and medication compliance. The manager expressed the view that it is possible to write too much in care plans, resulting in them not being read. Whilst it is important to make the plans accessible and as concise as possible, the care plans viewed are inadequate for the reasons cited above. Currently only the team leaders write care plans (although keyworkers have input into the process, including through conducting monthly reviews of care). Some staff expressed surprise at the content of certain plans, calling into question whether they are working documents which are referred to and which form the basis of consistent practice within the teams. As well as involving service users more in the care planning process, the team should consider whether staff should become more involved in writing and reviewing them. The manager must also ensure that all staff involved in writing care plans have appropriate training in care planning. Care plans are currently hand written in most cases. Typing them would make them easier to read, and would make amendment easier provided the documents are stored on computer. The concept of person centred planning was discussed. Some staff pointed out that most of the service users had primary needs relating more to mental health difficulties (although some people’s primary needs do relate to a learning disability). Nonetheless it is an approach to care panning which is also being increasingly adapted for use with people with mental health difficulties, and the tools and underlying principles could be adopted at Pfera Hall. In addition to restrictions and limitations in care plans which did not always have a robust justification, there were many restrictions in place around the three units which did not appear to be recorded in a risk assessment format. For example, the locking of kitchens, bathrooms and laundries. Whilst there may be valid reasons for these restrictions, where they are in place they must be fully documented and kept under review and, as far as possible, agreed with service users. Service users reported that they were expected to be in their bedrooms by 23.00, some expressing their dissatisfaction with this. This is another example of a restriction which was not referred to in any of the documentation seen during the inspection and which appears somewhat arbitrary. There are also issues around service users’ rights. The manager and staff explained that, for some people in particular, it was necessary to promote a structured routine which included retiring for the night reasonably early. Whilst this is accepted, where this is an identified need this should form part of individuals’ agreed care plans and should always be balanced with people’s rights to choose when Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 13 they go to bed in their own home. An example was found of an incident when staff attempted to force a person up the stairs with physical intervention having refused to go to bed (see Standard 23). Staff were seen offering choices to service users, who in turn reported that they were offered choices in areas such as diet and activities. The manager reported that service users had been offered advocacy and that some people had taken this up over particular issues or on an ongoing basis. This is good practice. Risk assessments in three service users’ files were checked. In some cases assessments had been written to cover key risk issues and how these were to be managed. Examples included risks of harm to self and others, and the required numbers of staff to be with the person in community settings. However, in one case there were no risk assessments in the relevant section of the file. Another person had a risk assessment about violence dated January 2003 but no other risk assessments and risk management plans were in evidence (such as an assessment forming the basis of a decision about numbers of staff required to support the person in the community). This is particularly concerning given the complex needs of the service users living at Pfera Hall and the significant risk issues associated with this. It was reported that a new risk assessment format was gradually being introduced. An example of this was seen. Some staff have received training in risk assessment, and more staff were due to attend this course on two dates in March 2006. Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 14 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): 16 Service users’ rights are not always fully respected, impacting on their independence and autonomy. EVIDENCE: Service users expressed satisfaction with their activities both in the home and the community. Staff felt that service users were offered diverse, individual programmes, though reported that staffing levels could impact on this (particularly for people who required 2:1 or 3:1 support in the community). Positive comments were received from health and social care professionals involved with the home about activity provision, including that good use was made of facilities in the community and that high quality daycare was provided on site. As noted earlier in the report, whilst there was evidence of service users being offered choice, there were also significant limitations and restrictions in place which were not always appropriately assessed and documented. Examples included an expectation that service users would be in their bedrooms by 23.00 and one person’s care plans defining very tightly the times that they Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 15 could use their bike in order that it did not ‘interfere with mealtimes’ (indicating a lack of flexibility of routine). It is accepted that some service users benefit from highly structured routines and require significant prompting and guidance to keep to these. However, these need to be fully documented/justified and reviewed on an individual basis, with service users being involved as much as possible. Some training is provided by the organisation about service users’ rights/empowerment. It would be appropriate for all staff to receive this training. Staff reported aiming to promote service users’ independence and to encourage participation in household tasks as much as possible. In the last report a recommendation was made to aim to record the vegetables and other accompaniments provided with each meal in the records of peoples food intake, as part of monitoring whether the diet is balanced. Records of food provided evidence that whilst this was being done in done cases it was not consistently applied. Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 19 Additional work needs to be done to ensure that service users are receiving personal care in ways which fully respect their preferences and that their privacy and dignity is respected at all times. There is scope to improve systems for monitoring people’s access to healthcare services as part of ensuring that people receive the care that they need to remain well. EVIDENCE: Some staff described how they provided personal care support to service users, and how they aim to respect people’s choices and preferences in this area. They stated that only female staff support female service users, though said that female staff did provide male service users with personal care. As noted in Standard 6, care plans in the home need overhaul. As part of this, care plans relating to personal care should include people’s preferences about how this is delivered, including whether they have any wishes about the gender of the person providing the support. Monitors are in use in various parts of the home. Protocols for their use need to be drawn up which describe when they are used and for what reason, along with measures in place to safeguard service users’ privacy and dignity. At one point a monitor was on in an office allowing one person’s support in the shower Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 17 to be overheard. However, it is recognised that at present staff may have no reasonable alternative in terms of promoting health and safety (see Standard 42). One service user has a massage once a fortnight, conducted by a staff member. The person does this when they are off duty and it has been confirmed that they are qualified. A care plan is in place, which includes another person being present. However, the inspector has some concerns about this in terms of: • • • • How it is demonstrated that the person has made a fully informed choice including being offered a masseur providing a service in the general community. Potential conflict of interest issues given that the staff member is receiving private payment for the service. Possible impacts on the relationship between the service user and staff member. There could also be issues around this becoming a longer-term arrangement involving exchange of money, and the service user possibly feeling obliged to continue it. There would therefore need to be an independent review. It is recommended that the arrangements be fully reviewed in the context of the above considerations. However, there was evidence that the service user was benefiting from the experience. Health records were checked in respect of three service users. However, staff reported that records of appointments would form part of daily records (as well as being recorded in the diary). It was therefore difficult to quickly establish when service users had most recently had routine healthcare appointments. Such a system also increases the potential for some routine healthcare to ‘slip through the net’, although direct evidence of this happening was not found. Many homes have a separate recording format for different healthcare appointments so that this information can be easily accessed. The manager acknowledged the above and described plans to adopt health action planning (or an adapted version suitable for the needs of service users living in the home). This should be done as soon as possible. Correspondence indicated that people living in the home were receiving appropriate specialist healthcare services such as psychiatric reviews. The manager described a private contract which the home has for emergency psychiatric care (including in-patient admission if needed). Additional services are also bought in from other sources. This includes clinical psychology input. See also Standard 2 regarding RMO cover for a new admission. Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 18 Standard 20 was not assessed during this inspection. However, the pharmacist inspector visited the home on February 2nd 2006 and conducted an audit of the handling of medication in the home. Significant shortfalls were found in a number of areas, resulting in 15 requirements (including three immediate requirements) and five recommendations being made. An action plan has been received in respect of these findings and compliance will be checked during future inspections. Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 19 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 Systems are in place to take forward concerns and complaints, although there is scope for improvement, including developing a culture and environment where service users consistently feel able to informally and formally express any issues they may have. Improvements need to be made to how challenging behaviour is managed and recorded in the home in order to promote service users safety, dignity and rights, as well as to help protect staff. EVIDENCE: The organisation has a complaints procedure. There are versions in text and symbol format. The version seen in the home during the inspection required update since it referred to the NCSC. The manager understood that this was shortly to be done. He reported that there had been no formal complaints in the last 12 months. The manager was confident that service users knew of their right to complain, citing examples, although some staff were less certain about this. Some service users spoken with said that they would feel able to voice concerns and complaints, saying that they thought staff would listen and respond well, although other people were more circumspect about this. Service users will need to be supplied with a revised copy of the complaints procedure in a format appropriate to their needs. It may be helpful as part of this to talk through with each person about their right to complain and how they go about this should they so wish. Service users’ care plans in respect of challenging behaviour were checked. In some cases there were additional notes (such as from a clinical psychologist) Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 20 and background material (such as from the community team providing ongoing input). However, care pans covering areas such as impulsive behaviour, selfharm, suicide and agitation were extremely brief and did not provide clear guidance for what staff should do to help prevent challenging/high risk behaviour or what to do should it present. In some cases acute incident sheets confirmed that there were incidents of restrictive physical intervention but the service users in question did not have individual protocols which made reference to this possibility and to the approach(es) to take. One care plan seen stated that staff should use Studio Three techniques if required without indicating what this meant in the context of that person. Staff spoken with were able to describe what this meant but the plan did not reflect this. Behaviour monitoring charts were seen in some files. Staff were recording whether the person’s behaviour fell into the categories of red, amber or green for the time period in question. However, in most cases there were no accompanying notes which described what constituted red, amber or green behaviours for that person. This can lead to inconsistency of recording. Acute incident records which referred to the use of physical intervention and/or Studio Three techniques often did not define what these were. Where restrictive physical intervention is used Regulation 13 (8) requires that the nature of the restraint be recorded. A record from 29/12/05 (23.30) stated that a service user refused to go to bed saying that they were going to stay up until 1am. Staff asked again, sought help from other staff and repeated the request. The following was recorded, “[service user] said no so he was escorted to the stairs using Studio Three techniques…as [service user] was going backwards he fell on the stairs”. It was not clear what techniques had been used. The manager said that the 23.00 bedtime was encouraged rather than enforced, and agreed that the circumstances as described in the report did not justify the use of restrictive physical intervention. Nor would what was written appear to fall into the categories of last resort and exceptional circumstances. That the person fell on the stairs suggests that this was a high-risk intervention for all concerned. Another acute incident sheet from ‘23/11’ (no year recorded) described how one person who was outside was unsettled and was therefore asked to come into the building. Studio Three techniques were used twice during this intervention according to the record, but it was not clear exactly what the circumstances were that justified the use of restrictive physical intervention. If there is a clear need for the person to be brought inside in such circumstances (rather than remain outside) then the report needs to describe this. The deputy manager was reported to be doing an analysis of acute incident records to check their content and also establish whether the incident needs to be reported to CSCI. This could be extended to include considering whether the use of restrictive physical intervention is justified/a last resort in Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 21 exceptional circumstances and whether it accords with individual plans and protocols for the person concerned. There may also be opportunities to see patterns, identify triggers and ultimately to contribute to the promotion of an overall decrease in the incidence of challenging behaviour and use of restrictive physical intervention. Training in record/report writing should be provided for all staff. The Commission has had to ask for clarification in respect of some Regulation 37 notifications since the information and reports provided were illegible and/or inadequate. It is acknowledged that Pfera Hall provides a service for individual with very complex needs who may present significant challenges to the service. Staff were able to describe low arousal techniques, and reported that in their experience challenging behaviour was managed well. Positive feedback was obtained from health and social care professionals, who expressed confidence in the ability of the team to understand and manage challenging behaviour. One service user felt that staff provided appropriate support if they were unsettled, saying ‘they help calm me down and make me laugh’. Another person said that they felt safe at Pfera Hall. Some records of service users’ finances (including receipts) were checked. These appeared to be in order. However, it was noticed that loyalty cards had been used with transactions for two different service users in the same unit (Dorabella). Staff confirmed that the service users themselves did not have loyalty cards. It was suggested that it may be a ‘house’ loyalty card (although the card numbers on the two receipts were different). This needs to be investigated to ensure that staff are not profiting from transactions involving service users’ money. Even if it is a house card this raises questions about how service users (who will inevitably contribute at different rates to any accrued benefits) share the eventual loyalty bonus. The manager described how issues around staff being related to one another are managed in the home. A letter will be written to the organisation requesting a copy of the written policy on this issue. Records indicated that relatively few staff had received training in the protection of vulnerable adults/prevention of abuse. This should be provided for all staff. Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 22 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Some improvements need to be made to the environment in order to make the home more pleasant and safe place to live and work. A clean and hygienic environment is generally maintained, promoting service users’ wellbeing. EVIDENCE: The three units was not systematically checked. However, the communal areas in Dorabella and Winston were looked at, along with some service users’ rooms where there was an invitation to view the room from the person). In general the areas viewed were in reasonable condition and it is acknowledged that they can be subject to a high degree of day-to-day wear and tear. The following issues were noted which require attention (some prompted by a recent Regulation 26 report): Dorabella: • The ground floor toilet was out of liquid soap. The room has flaking paint, particularly around the doorframe, and would benefit from repainting. DS0000016539.V286268.R01.S.doc Version 5.1 Page 23 Pfera Hall • • • • • A black bin liner and washing basket full of objects apparently being disposed of had been left in an alcove by the exit. This is unsightly and could also form a fire hazard. The lowest shelf in one freezer was cracked and requires replacement. The other freezer required defrosting. The first floor shower produced water in a dribble rather than a jet. One person had no curtains. Staff described the reasons for this. Nonetheless this needs to be addressed in consultation with the person. Winston: • • • • • • • The ground floor toilet had a basin where the hot water was recorded as being 30.3°C, which is too cool. The hand basin in the kitchen is very stained and worn. An emergency light on the landing is not working. A light in the dining room is not working. The door closure mechanism on the smoking room required urgent repair. Work needs to be done to ensure that rooms one and two are sufficiently warm (although they were unoccupied at the time). Room 1 also has a damp area on the ceiling. Some staff pointed out that there were no secure storage facilities for personal belongings, resulting in people leaving things around the office. The Care Homes Regulations require that there be suitable storage facilities for staff. For example, many homes offer lockers. Some people also felt that a staff room should also be provided. All three units had a noticeably smoky atmosphere. Many of the service users smoke. Two of the units have a smoking room, although Nimrod does not have this facility. Some staff expressed concerns about the smoky atmosphere, as did some health and social care professionals providing feedback. Consideration should be given to ways of reducing this, such as fitting extractor fans into the smoking areas. Ideally there should be provision for people to smoke in a location which does not then result in a smoky atmosphere throughout the units. Much of the crockery in Winston was chipped. Staff reported that this was an ongoing issue and that it was regularly replaced. On the day of the inspection a staff member was due to purchase some more. Cleaning rotas and checklists were seen. The home appeared to be generally clean throughout. There is a cleaner for the office and daycare area, but it is the responsibility of staff and service users to keep the accommodation clean. Staff said that, in practice, they undertook almost all of the cleaning of the communal areas. The manager acknowledged this, though felt that providing a cleaner for the three units may make the settings feel less homely. Concern Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 24 was also expressed about this discouraging service users from taking responsibility for cleaning and also making it feel less like their home. Nonetheless, consideration should be given to the possibility of employing a cleaner for the communal areas since there was evidence that a considerable amount of staff time (both nurses and support workers) was being devoted to cleaning. Some staff in Winston felt that one washing machine was inadequate, and that a second machine (domestic in scale) was needed so that more than one person could do their washing at the same time. They felt that this would be essential should more people be admitted (The unit had vacancies at the time). In Nimrod there is a ground floor toilet which is kept locked and which is for staff use. The toilet should be accessible to service users as well as staff. Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 25 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, 33, 34, 35 & 36 Staff are skilled and competent, although there is scope for further professional development in a number of areas in order to improve the quality and consistency of care. Staffing levels in the home are inadequate, compromising service users’ quality of life and presenting health and safety risks for service users and staff. Recruitment and selection procedures in the home are generally satisfactory, although some improvements are needed to make the systems more robust. Shortfalls in staff training and supervision could significantly compromise the quality of care provided. EVIDENCE: The manager felt that the home was approaching the target of 50 staff being qualified in NVQ care or equivalent. He said that two staff had just completed a certificate in community mental health (seen as more relevant that NVQ in care in this setting) and that more people would enrol this semester. A training requirements matrix for 2006 indicated that 6 staff (out of 35 recorded excluding the manager) had obtained the certificate in mental health and that five people were registered on this course or an equivalent. The figure of 35 staff includes a number of qualified nurses who would not be expected to undertake NVQ in care qualifications. Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 26 Service users reported that staff were good listeners and that they felt comfortable approaching them. Feedback from health and social care professional about the competence and skills of the staff team was positive. Staff spoken with were able to demonstrate a knowledge of service users’ needs and conditions. They felt that they worked well as a team and cited examples of good practice resulting in positive outcomes for service users. Some review notes from healthcare professionals provided evidence of the team doing excellent work. For example, one letter from a consultant dated December 2005 stated that whilst living at Pfera Hall their client ‘has done significantly well in terms of his mental health’. The Commission has been made aware of some allegations concerning areas such as staff attitudes & values and adherence to care plans. There is evidence that the organisation has taken the necessary steps to safeguard service users and investigate allegations thoroughly. As indicated elsewhere in the report, there is evidence that some staff have development needs in areas such as care planning & risk assessment, assessment and documentation around restrictions & limitations, and in report writing. There is also evidence that restrictive physical intervention may have been inappropriately used on occasions. As noted later in this section, there are also gaps in basic training for some staff. Staff spoken with consistently expressed that staffing levels in the home were too low. They said that this was impacting on activities – in particular for people who required 2:1 or 3:1 support in the community, resulting in them going out less often than they would like to. Some felt that this was leading to an increase in service users’ frustration and boredom, resulting in turn in a higher incidence of unsettled and challenging behaviour. Many staff also expressed health and safety concerns associated with low staffing, particularly during incidents of violence and aggression. Some people described having to send a service user to fetch help, giving them the security code to access another unit in the process. Other staff described working long hours and doing overtime to the point where they felt exhausted. The following are extracts from a review in February 2006 for a person who requires considerable support in the community: ‘…enjoys going out but this can be difficult to achieve due to problems with staff levels…will participate in activities when interested and staffing levels allow…’ The manager acknowledged that the home was short staffed, and said that recruitment was taking place. Some interviews were arranged for the final day of the inspection. The situation must be addressed, with staffing levels being appropriate to meet service users’ needs. Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 27 Many people working in the home said that staff meetings were infrequent and irregular. This should be addressed. The recruitment procedure was described. This would usually include an informal visit to the home in order for candidates to have a clearer idea of the job/setting. There is a six-month probation period. Three staffing files were checked. These appeared to be in order apart from one file having an application form (dated February 2005) with gaps in the employment history. An account of these gaps was not found elsewhere on the file. The organisation currently obtains one professional reference, and one or two personal references. Personal references should be seen as supplementary, and two professional references should be obtained as far as possible (Schedule two of the Care Homes Regulations provides further information about sourcing the references if the person has previously worked in social care). The home currently retains copies of CRB certificates. The inspector understands that these should be destroyed once viewed during an inspection, although a record can be kept of one having been done. The organisation has a training manager. Courses available during March 2006 included health and safety, self-harm, first aid, sexuality awareness, protection of vulnerable adults, loss and bereavement, Studio Three (managing challenging behaviour), risk assessment and person centred support. A memo provided evidence of staff from Pfera Hall being put forward for some of these courses. The manager also described a change to the rota whereby training time was now built into people’s working hours. However, records indicated that a significant number of staff had not received training in basic areas such as first aid, fire safety, food hygiene, moving and handling. In addition, there was evidence that staff were not receiving regular refresher training in Studio Three (in one case sampled there had been no input since 2001 according to records). This must be addressed and appropriate systems put in place to ensure that staff remain as up to date as possible with core training (including refresher training in the management of challenging behaviour at suitable intervals). Staff spoken with were generally positive about the organisation’s commitment to training, including the home providing and facilitating access to relevant specialist training and professional development. However, some expressed concern about gaps in mandatory training, a lack of regular refresher training in Studio Three and about a lack of training about the particular mental health conditions experienced by some service users. Some people also felt that there should be input about reflective practice. Some staff said that there was a policy of asking people to repay the cost of training if they subsequently left Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 28 employment within a specified time period, and that this acted as a disincentive to undertake training. Recommendations are made elsewhere in the report about other forms of training which would be appropriate for staff to attend. The manager described the induction format, although this was not explored in detail during this inspection. Given that recruitment is underway, this is an area which will be looked at in the next inspection. Staff commented that they received very infrequent formal supervision. In some cases people said that they had not had a supervision meeting for over two years. A meeting was due to take place in one of the units shortly after the inspection to allocate supervisors to support workers. The manager agreed that supervision had become ‘patchy’ and said that he was acutely aware of the need for this to be prioritised. It was pointed out that there was nowhere for senior staff to securely store supervision notes in a location which was accessible only to the supervisor. Such facilities should be provided. Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 29 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 is not run as well as it could be, resulting in a service which performs below its potential. Quality assurance systems are in place in the home, although these could be improved in order to obtain more regular feedback from service users and other sources. Aspects of health and safety in the home need improvement in order to promote the wellbeing of service users and staff. EVIDENCE: The registered manager is a nurse. He said that he was in the process of completing the registered manager’s award and expected to finish this within the next five months. Following this he is hoping to undertake the nursing degree. Staff spoken with were generally positive about how the home was run. Comments included that the manager was accessible, caring and helpful. Some Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 30 felt that leadership could be stronger, for example in terms of taking forward concerns and issues raised until a satisfactory outcome is reached. There was also an observation that the manager was undertaking a considerable number of care shifts due to the staffing situation, taking him away from management tasks. This was observed during the inspection. Whilst it is important for a manager to stay in touch with what is happening ‘on the ground’, including through working in the unit, there was evidence that the degree of this (necessitated by the staffing situation) was impacting on the running of the home. Whilst taking the above into account, as noted throughout the report shortfalls were found in a number of key areas (including by the pharmacist inspector during their visit), suggesting that there is considerable scope for improvement in the overall management of the home. Clearly the service provider has responsibilities in this area as well as the home manager. Many of the issues noted in this report have appeared in previous reports. See for example the report dated September 1st and 2nd 2004. The home has achieved ISO 9000 certification. The last audit by relating to this took place in September 2005 and resulted in no issues being raised. Staff reported that service users’ views are sought on a day-to-day basis, and also during monthly reviews with their keyworker. There was evidence that some service user meetings have taken place, but that these are infrequent. As part of quality assurance a new manual has been circulated to the units, including new procedures in a number of key areas. The home has a policy of conducting an annual survey of stakeholders (service users, family and professionals involved in service users’ care). The manager said that the results of these surveys are discussed at monthly management meetings. However, the most recent survey on file was from February 2004. It therefore appeared that another survey was overdue. As noted elsewhere in the report, some service users felt less confident in voicing concerns and complaints, and there may be work to do in developing systems and a culture whereby all of the service users feel more empowered to express their views. However, other service users did say that they were confident raising issues. Regulation 26 visits are being undertaken monthly and detailed reports are being forwarded to CSCI. One person had just purchased a bed. Staff explained that they provide standard single beds but that people can choose to buy a different type of bed if they wish. Their inventory could not be located. It is recommended that this be checked to ensure that the bed has been added to their list of belongings. Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 31 Aspects of health and safety in the units were checked. Staff are expected to conduct a range of different checks at set frequencies. Examples of the completed templates were seen. Vehicle check forms were also viewed. Fire logs in two units were seen. The fire log in Winston indicated that fire alarms were not consistently being checked on a weekly basis. A chemical marked as an irritant was found in an unlocked cupboard in a toilet in Dorabella. Staff confirmed that this should have been locked away in designated cupboards. Training records indicated that many staff have undertaken training in health and safety. However, as noted, there are significant gaps in other areas of core training which have implications for health and safety. The issues around short staffing identified in this report also present risks for the health and safety of service users and staff. Some staff felt that the short staffing made the home an unsafe place to work. Staff in two units raised concerns about summoning help if required, for example, during an incident of challenging behaviour. As noted, staff reported having to send a client for help, giving them a door code. ‘Pull alarms’ which make a loud noise had been tried, but were not always heard by colleagues in other units. Staff have been issued with walkie-talkies but staff said that these were of limited practical use and could also be overheard by other handsets in the local area, raising a significant confidentiality issue. Some staff suggested that a push-button alarm system carried by all staff would be appropriate, and that this should send a signal to panels in all three units which would then flash and make a noise. It is not for CSCI to determine the exact nature of the system for calling for assistance, provided that the outcome is an effective and reliable system that promotes the health and safety of service users and staff without compromising service users’ confidentiality. Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 32 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 1 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 2 33 1 34 2 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 x 1 x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 2 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 x x 1 x 2 x x 1 x Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 33 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. Standard 1 YA2 Regulation 14 (1) d Requirement Provide confirmation in writing to new service users being admitted that the home is suitable for meeting their needs in respect of health & welfare (so far as it is practicable to do so). Ensure that care plans describe how service users’ needs in respect of health and welfare are to be met and that, unless impracticable, there has been appropriate consultation with the service user. Ensure also that care plans are kept under review and revised as necessary. All staff involved in writing care plans must have appropriate training in care planning. Where restrictions are in place they must be fully documented and kept under review and, as far as possible, agreed with service users. Ensure that appropriate systems are in place for identifying, assessing, documenting and managing significant risks. Regularly review and update risk DS0000016539.V286268.R01.S.doc Timescale for action 31/03/06 2 YA6 15 (1) & (2) 31/07/06 3 4 YA6 YA7 18(1)a & (c)(i) 12(1,2&3) 15 S.3.3 q 12(1) 13(4) 31/07/06 31/07/06 5 YA9 30/06/06 Pfera Hall Version 5.1 Page 34 assessments as required. 6 YA18 12(4)a Protocols for the use of monitors need to be drawn up which describe when they are used and for what reason, along with measures in place to safeguard service users’ privacy and dignity. Update the complaints procedure as described in the text. Give service users a copy of the updated procedure. Clear and comprehensive care plans/individual protocols must be devised about the management of challenging and high-risk behaviour. Where this involves planned physical intervention in certain circumstances this must form part of the plan/protocol. Where restrictive physical intervention is used there must be a clear record of the nature of the physical intervention technique used. Restrictive physical intervention must only be used as a last resort and in exceptional circumstances. Investigate the scenario described in the text to ensure that staff are not benefiting from service users’ financial transactions through the use of loyalty cards. • Ensure that liquid soap dispensers in toilets are stocked at all times. • Ensure that rubbish/objects being disposed of are promptly removed from the home. • Defrost the freezer in Dorabella which is congested with ice. • The ground floor toilet in Winston was producing hot DS0000016539.V286268.R01.S.doc 30/06/06 7 YA22 22 30/06/06 8 YA23 12(1) 13(4&7) 15 31/07/06 9 YA23 13 (8) 31/03/06 10 YA23 12(1) 13(4&7) 12 (1) & (5) 31/03/06 11 YA23 30/04/06 12 YA24 13(3) 23(2)b&d(4) 31/03/06 Pfera Hall Version 5.1 Page 35 • • • water at too cool a temperature. This needs to be rectified. Repair the emergency light on the landing in Winston. Repair the light in the dining room in Winston which is not working. The door closure mechanism on the smoking room in Winston requires urgent repair. The lowest shelf in one freezer in Dorabella was cracked and requires replacement. The first floor shower in Dorabella produced water in a dribble rather than a jet and requires maintenance work. Ensure that one person in Dorabella is provided with appropriate curtains or blinds for their bedroom as noted in text. The hand basin in the kitchen in Winston is very stained and worn and requires replacement. Work needs to be done to ensure that rooms one and two in Winston are sufficiently warm before any service users move into these rooms. Room 1 also has a damp area on the ceiling which needs attention. 30/04/06 13 YA24 12(4) 13(4) 16(2) 23 • • • 14 YA24 23 • 31/07/06 • 15 16 YA24 YA33 23 (3) a 18 (1) a Provide suitable storage facilities 31/07/06 for staff. Ensure that all times there are 31/03/06 enough staff working in the home to meet service users’ needs in DS0000016539.V286268.R01.S.doc Version 5.1 Page 36 Pfera Hall respect of health and welfare. 17 YA34 19. Sch.2(6) Ensure that staffing files include a full employment history and a satisfactory written explanation of any gaps in employment. All staff must receive training appropriate to the work they perform. This must include refresher training in the management of challenging behaviour at suitable intervals. All staff must be appropriately supervised. Fire alarms must be tested at suitable intervals (at least once a week). Ensure that hazardous chemicals are locked away if necessary. Implement an effective and reliable system for calling for assistance which promotes the health and safety of service users and staff without compromising service users’ confidentiality. 30/04/06 18 YA35 12 13 18(1) 23 18(2) 23 (4) c 12 13 12 13 (1) (4) (1) (4) 31/07/06 19 20 21 22 YA36 YA42 YA42 YA42 30/04/06 31/03/06 31/03/06 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA2 YA2 Good Practice Recommendations Direct contact with service users’ RMOs should be made during the admission process in order to fully clarify ongoing service provision. The home should conduct its own thorough needs assessment with prospective service users (to include appropriate consideration of risk issues/management) in all cases. • Consider whether the wider staff group should become more involved in writing and reviewing care plans. • Explore the principles of person centred care planning and the tools currently available for this. Consider DS0000016539.V286268.R01.S.doc Version 5.1 Page 37 3 YA6 Pfera Hall implementing a more person-centred care planning system in the home. • • • Revise the care planning format to use positive language rather than the heading ‘problem’. Consider if some care plans are duplications and/or should be combined. Aim for care plans to more directly reflect service users’ own aspirations and goals. Where a structured and staged programme towards a particular aim is in place ensure that the care plan fully reflects how this is to be carried out. 4 5 6 YA16 YA17 YA18 7 8 YA18 YA19 • Aim to type all care plans. Provide training for all staff in promoting service users’ rights/empowerment. Aim to record the vegetables and other accompaniments provided with each meal in the records of peoples food intake, as part of monitoring whether the diet is balanced. Care plans relating to personal care should include people’s preferences about how this is delivered, including whether they have any wishes about the gender of the person providing the support. Fully review the arrangement of a staff member providing a massage for a service user, including giving consideration to the issues noted in the text. Improve monitoring and recording systems around healthcare as described in the text. Adopt a ‘health action planning’ format and framework (or an adapted version as suitable for the needs of people living in the home) as soon as possible. Following distribution of the updated complaints procedure it may be helpful to talk through with each person about their right to complain and how they go about this should they so wish. Where systems are in place for recording patterns of behaviour in terms of ‘red, amber or green’ then there should be accompanying individualised notes defining these categories. Broaden the audit of acute incident records as described in the text. • Training in record/report writing should be provided for all staff. • Training should also be provided for all staff in the protection of vulnerable adults/prevention of abuse. DS0000016539.V286268.R01.S.doc Version 5.1 Page 38 7 YA22 8 YA23 9 10 YA23 YA23 Pfera Hall 11 12 13 YA24 YA24 YA24 14 15 16 17 18 19 YA24 YA30 YA30 YA33 YA33 YA34 20 YA34 21 YA35 The ground floor toilet in Dorabella should be redecorated. Consider whether a staff room should be provided. Consideration should be given to ways of reducing the smoky atmosphere throughout the home, such as fitting extractor fans into the smoking areas. Ideally there should be provision for people to smoke in a location which does not then result in a smoky atmosphere throughout the units. The ground floor toilet in Nimrod should be accessible to service users as well as staff. Consideration should be given to the possibility of employing a cleaner for the communal areas in the three units. Provide a second washing machine in Winston. Avoid the practice of staff working excessively long shifts to the point where this impacts on the quality of care provided. Reintroduce regular staff meetings (at least six per year). Personal references should be seen as supplementary, and two professional references should be obtained for each candidate as far as possible (Schedule two of the Care Homes Regulations provides further information about sourcing the references if the person has previously worked in social care). CRB certificates should be destroyed once viewed during an inspection, although a record can be kept of one having been done. Information about this and the record to keep on file could be sought directly from the Criminal Records Bureau. Training should be provided for all staff about the conditions experienced by some service users, such as particular mental health conditions. Consider also whether there is a need to provide training in reflective practice. Conduct another survey of stakeholders (including service users) as part of the quality assurance strategy. Check that the bed recently purchased by a service user in Dorabella has been added to their inventory of belongings. 22 23 YA39 YA41 Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 39 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pfera Hall DS0000016539.V286268.R01.S.doc Version 5.1 Page 40 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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