Inspection on 22/06/06 for Pfera Hall

This inspection was carried out on 22nd June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is 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 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 28 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 10/03/06

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 Key Unannounced Inspection 22 , 23 and 26th June 2006 09:30 nd rd Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 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.V301979.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th March 2006 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, a training kitchen and an art & craft centre. The home has several vehicles in order that service users can access facilities and amenities in the wider community. Fees were reported to range between approximately £2500 and £2800 per week. Prospective service users and their representatives are provided with information about the home including copies of the Statement of Purpose and Service Users Guide. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over three days, each beginning at around 10am and lasting until late afternoon. Many of the staff and service users were met and spoken with over the course of the visit. A range of records was also checked in each of the units and in the main office. These included care plans, risk assessments, daily notes and financial records. A return visit was made on Friday June 30th to provide feedback to the manager and deputy manager. The pharmacist inspector visited the home on 20/06/06. Their findings are included in this report. The reason for this visit was to carry out an inspection of the arrangements for handling of medicines. This forms part of the key inspection of the home and was at the request of the lead inspector to monitor progress following the pharmacist inspection in February 2006 when a number of concerns about the safe handling of medicines were identified. Medicine stocks and storage arrangements, Medication Administration Record (MAR) charts and other records and procedures relating to medication were looked at. The manager and one other member of staff were spoken to. The inspection took place over a 3-hour period. What the service does well: What has improved since the last inspection? The complaints procedure has been updated (although copies have not yet been supplied to service users as required). The management of medicines has improved and many requirements from the last inspection have been actioned. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 6 Staff have been reminded not to use their loyalty cards when service users’ money is spent. There have been some improvements made to the environment to make it safer and more homely. More staff have been taken on and agency staff are also being used to help cover remaining shortfalls. Recruitment procedures have been tightened up to make sure that they comply with legislation. Some progress has been made with providing staff with appropriate training and supervision. There is also a new supervision and support structure in place for the manager. What they could do better: There is scope to improve the admissions process, in order to help make sure that the home will be able to meet service users’ needs before a place is offered. Shortfalls in the procedure around the most recent admission were having ongoing consequences for staff and service users, resulting in questions being raised about the safety of the placement. Care planning in the home needs to be improved so that care plans more fully describe how people’s needs are to be met. Systems for formally assessing and managing risk also need to be significantly improved. Whilst choices are offered in many areas of day-to-day life, there are also major restrictions on service users’ freedom, rights and decision-making which need to be more fully considered, and to be appropriately documented and justified. There was some evidence that service users with complex needs may not have access to a full range of appropriate activities. Although there was evidence that people are receiving the personal support and healthcare that they need there is scope for improving aspects of this care such as in terms of care planning and recording. Some further work is needed to make sure that medicines are managed as safely as possible. There was evidence from various sources that concerns, allegations and whistle blowing are not always being handled appropriately, compromising service users’ safety as well as staff members’ confidence in procedures for managing issues that they raise. Improvements need to be made to certain practices and recording around restrictive physical intervention. Individual protocols are also needed about the management of challenging behaviour. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 7 Whilst staff work hard to maintain a homely and welcoming environment, there are a number of maintenance issues which need attention. The home has not been notifying the Commission of important events. Improvements need to be made to some aspects of the handling of service users’ finances in order to reduce the chance of errors being made. Although staffing levels had improved there was evidence that they were still not sufficient. Further improvements also need to be made to staff training and supervision. Some basic health and safety shortfalls need to be addressed. This inspection has resulted in a significant number of requirements being made or repeated. CSCI will expect a clear plan of action and improvement from the service provider about how these issues will be addressed. The Commission will consider taking enforcement action unless there is significant and sustained improvement. 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.V301979.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is scope to improve the admissions process, helping to ensure that service users’ needs can be met before a placement is offered. EVIDENCE: The home has an appropriate admissions procedure and a referral form. A preassessment summary form also exists which can be used to gather some basic information about the person referred. The manager said that when there is a referral he conducts an assessment, often with the service’s lead psychologist, over several visits. During the last inspection no needs assessment by staff at Pfera Hall was evident on the file of the person most recently admitted. During this inspection another file was checked for a service user admitted in August 2005. Whilst there was a significant amount of detailed and relevant background information and external assessment material there appeared to be no record of an assessment by staff at Pfera Hall. Such assessments should be recorded in full and stored in the person’s file with other background and assessment material. There had been no new admissions since the last inspection. In the previous report a requirement was made to confirm in writing to new service users being admitted that the home is suitable for meeting their needs in respect of Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 10 health and welfare. The manager said that this would be done in future. This step could be added to the admissions procedure. An important issue relating to ongoing service provision by healthcare professionals for the person most recently admitted had still not been resolved at the time of the inspection. This was highlighted in the past report as a significant shortcoming in the admission procedure. The manager said that in future he would ensure that there was written confirmation of service provision before a person would be admitted. However, there was evidence throughout the inspection that the person’s needs were still not being entirely met and that fully appropriate care plans and risk assessments were not yet in place. A letter dated 21/06/06 from a healthcare professional indicated that without a proper handover of care the placement could be deemed unsafe. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care planning in the home is inadequate, increasing the risk of inconsistent practice and of service users’ needs not being met. Whilst choices are offered in many areas of day-to-day life, there are also significant restrictions on service users’ freedom which are not appropriately documented and justified. Risk assessment in the home is poor and does not promote effective and consistent risk management. EVIDENCE: In the last report a requirement was made to 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. Although the deadline for this requirement was 31/07/06, progress towards it was checked through sampling of care plans in the units. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 12 Some service users’ front sheets which include basic details were becoming tatty and hard to read, and some had amendments attached on loose pieces of paper. These should be rewritten if necessary. Care plans viewed continued to be headed with the term ‘problem’. This should be amended as described in the last report. One service user whose care plans were checked had a particular condition. The care plans did not clearly identify how the condition affects the person, other than describing manifestations in some areas. Care plans were unclear. For example, it was stated that staff needed to wash the person’s hair, but this did not clearly indicate how this should be done, whether it was hands-on or prompting/encouragement. There was no reference to the person’s preferences around the gender of the person providing support or to the promotion of independent living skills. The most recent review was dated as 31/12/05. A plan on diet gave only general advice. The most recent review stated that small meals were required, without saying what this meant or the reason and without the care plan being amended. A care plan about going out in the community stated that 3:1 support was needed, though no accompanying risk assessment indicated the reason for this. The plan included an instruction to ‘just go out for a drive if not calm enough’. Such an unclear statement could lead to very inconsistent practice with a direct impact on the person’s quality of life. Similarly there was a comment about if the person was not ‘up to it’ asking them if they were happy for staff to do their shopping rather than going out themselves. Care plans gave no clear reference to areas such as activity preferences, independent living skills and the person’s goals. The care plans and reviews provided no evidence of consultation with the service user. Some monthly keyworker reports recorded ‘n/a’ under service user’s comments. This does not accord with the home’s charter of rights which states that people will have their views and wishes valued. Several service users were asked if they had seen their care plans and replied that they had not. In a second person’s care plans there was some evidence recorded of discussion with the service user and more recent review. However, plans remained vague. A care plan about personal hygiene and clothes did not clearly define the reason for the intervention (presumably a risk of self neglect) and referred to staff providing encouragement without saying what this meant and what to do if this did not succeed. The person appeared to have just three care plans in place, with no clear reference to areas such as family, relationships, social needs, communication, diet, mental and physical health, challenging behaviour, activity needs and interests, personal goals or independent living skills. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 13 An OT report in July 2005 referred to the need to support the person to maintain and develop their daily living skills. A CPA review from the same month described the need for the person to maintain good physical health including oral hygiene, eat a healthy diet, and to develop appropriate cooking, domestic and social skills. Care plans did not reflect these objectives. A third person’s care plans were also vague and unclear. For example, a plan indicated that they needed to learn the difference between a friendship and a relationship with no indication of the history necessitating such a care plan or of the interventions which staff were expected to then provide. The manager described plans to review and revise all care plans, estimating that this would be completed within six months. The requirement for this deadline to be met was 31/07/06. This is therefore unlikely to be achieved. A requirement was made in the last report about all staff involving in writing care plans having appropriate training. Records of training showed that this had not yet been met (although the deadline was also 31/07/06). Recommendations about care planning which were seen not to have been actioned are also repeated. The Statement of Purpose notes the aim that service users will receive care appropriate to their needs. The Service Users Guide also notes that the service aims to maximise people’s independence (this being a unit for resettlement and rehabilitation). The shortcomings with the care planning system seriously compromise the ability of the service to meet these aims, although there was evidence from service users not case tracked that support was being provided to help them to develop independent living skills. The home’s Statement of Purpose includes some principles around choice. Service users spoken with felt that they were offered choice in day-to-day life. Staff were seen offering choice around areas such as diet. In the last report comments were made about an apparent expectation that service users would be in bed by 23:00. During this inspection some staff and service users indicated that this was the case, although others indicated that there was more flexibility, suggesting that practice may vary. Where there is an assessed need to promote a structured routine (which may include retiring for the night at particular times) this should form part of individuals’ agreed care plans and should always be balanced with people’s rights to choose when they go to bed in their own home. There are many restrictions in place around the three units which did not appear to be recorded (e.g. in a risk assessment format). For example, the locking of kitchens, bathrooms and laundries as well as the overall unit being secure. 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 Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 14 as possible, agreed with service users. The home’s charter of rights has a section about freedom of movement. This clearly states that a risk assessment will be in place in such circumstances. A requirement was made in the last report about this, also with a deadline of 31/07/06. Risk assessments for two service users were checked in more detail. One person had just one risk assessment on file (about violence – assessed as high risk) dated June 2003 with no linked management plan. The assessment had last been reviewed in May 2005. As noted, a care plan indicating that 3:1 support was required in the community was not accompanied by a clear assessment/justification for this. A second person had no risk assessments on file written by staff in the home. There were documents on file from previous settings/external agencies indicating a significant risk in areas such as violence and self-neglect. This is unacceptable and indicates significant shortcomings in the system of internal risk assessment and risk management. This is particularly concerning given the complex needs of the service users living at Pfera Hall and the significant risk issues associated with these. A requirement about effective risk assessment and risk management systems with a deadline of June 30th 2006 was extremely unlikely to be met. A letter from a healthcare professional dated 21/06/06 noted that in their view there were significant shortfalls in care planning and risk assessment for one person with very complex needs. The letter cited areas of significant risk which had been clearly identified before the person had moved to the home, adding that ‘Pfera Hall do not have any structured care plans in place in order to manage these risks’. In a subsequent response this was refuted by the service. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst there is good in-house activity provision, there is significant scope to improve overall provision in the home and community in order to meet service users’ individual needs and interests. Service users are supported to maintain important relationships in their lives. Service users’ rights are not always fully respected, impacting on their independence and autonomy. A balanced diet is provided, promoting people’s wellbeing, although care planning in response to assessed needs in this area would further promote people maintaining a healthy diet. EVIDENCE: A daycare plan provided a structured plan of activities for each service user. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 16 However, as noted, individual service users’ care plans viewed did not clearly identify their needs, interests and goals around activities. Daily records for two service users were checked. Staff reported that this would be where activities would be recorded. Over a 14-day period in June one person’s daily records indicated that they left the unit on just two occasions. The records suggested that the person spent most of their time either in the home (watching TV, listening to music or in their room) or in the garden. There was just one reference to attending daycare (although this appeared to relate to attendance not being recorded – see later section of report). Staff suggested that the person did not go out much due to issues with their morning routine and due to an assessed 3:1 staffing ratio in the community. They indicated that the person did much more in the past (such as swimming), but that particular circumstances and incidents had resulted in a reduced activity programme outside of the unit. A Social Services review from June 2005 noted that the person went out three or four times per week. Staff indicated that the person usually enjoyed going out, and that it was generally more appropriate for the person not to be accompanied by other service users. This suggested that staffing levels may be insufficient to meet the person’s needs and to promote the development of a suitable activity programme in a flexible and individual way. Staff in daycare said that the person attended quite often, but that there was no systematic way of recording this input. The person was observed in daycare on two separate days during the inspection. Occasional notes of daycare activities are made and there is some handover to staff in the units. It is strongly recommended that systematic daily records be kept by daycare staff of the sessions, linked to people’s care plans and identified needs, interests and goals. Staff described plans to write monthly daycare summaries in future. Files for two other service users in the same unit (where five people live) indicated that they required two to one staffing in the community. According to the rota two support workers are generally on shift in the unit in the daytime, with one team leader covering this and a second unit (see staffing section). The daycare team also provide assistance with activities. A second person’s records were checked over 14 days. On four of those days there was no reference to how the person had spent their time. The person had been out on five days, including spending some time with relatives and going shopping. A CPA review in July 2005 had stated that part of the home’s remit was to provide transport whenever the person wanted to go out. Daily records indicated that on 13/06/06 the person had asked to go to a supermarket but that had said that he may be able to on the following day (when no activities were recorded). Clearly it is unrealistic to expect that a service will be able to immediately respond to each person’s request to go out there and then, but staff spoken with consistently reported that staffing levels Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 17 were not high enough to be able to cater for individual needs as much as they would like. A review on 30/03/06 noted that the person preferred their own company and often asked to go out to local towns, but as they were unwilling to go with other people they did not take up all the opportunities open to them. However, if a person’s preference or assessed need is usually for activities which do not take place in groups then staffing levels need to reflect this, rather than expecting the person to fit in with the service. Staff reported that the person generally did not take part in their timetabled daycare activities, suggesting that, for whatever reason, an alternative approach to meeting the person’s activity needs may be required. More generally, this suggested a need for people’s daycare timetables to be more closely tied to care plans as well as to assessed, recorded needs, preferences and interests. Staff in daycare reported attending some relevant training, for example about teaching literacy skills. This is good practice. Further specialist training needs of staff working in daycare should be identified and measures put in place to meet these learning needs in accordance with the specialist nature of the role. Service users spoken with expressed general satisfaction with the activities offered. People were seen taking part in cookery and art sessions in daycare and appeared to be enjoying these. One person was asked about support to develop independent living skills and indicated that staff could do more in this area. Some people felt that there was not enough to do at weekends. Some staff also felt that this was the case, indicating that, for some people in particular this increased the likelihood of incidents of challenging behaviour, pointing to specific examples. Service users reported regular contact with family members (both visits and on the telephone). Daily records also provided evidence that this contact was facilitated. Comment cards from visitors/relatives provided positive feedback. There was reference to the high quality of care, excellent support in areas like activities and personal hygiene and to the caring nature of staff. People were seen getting up and having breakfast at different times, and choosing where they spent time over the course of the day. Service users’ files checked did not record their preferred form of address. This should be noted. Staff were observed supporting people to read and deal with letters in private. As noted, one service user’s monthly reports recorded their comments as n/a, which could be regarded as a denial of their rights. As also noted, there are many restrictions on people’s movement which, although they may be justified in terms of risk, are not documented and recorded. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 18 Some training is provided by the organisation about service users’ rights/empowerment and about attitudes and values. It would be appropriate for all staff to receive this training. Although no other specific examples were picked up during the inspection, some staff expressed general concern about service users’ rights not always being fully respected on occasions. Service users spoken with said that they were happy with the food and that they had choice about what they ate. People were observed being offered alternatives. Food records provided evidence of a balanced diet being provided. Fresh fruit was available in all of the units. Staff reported that fresh meat and vegetables were regularly used in cooking. Meals were observed to be relaxed, with the food well presented. One person whose care was tracked was reported to regularly refuse food. Staff said that it could be very difficult to encourage the person to eat a balanced diet. A letter from a healthcare professional dated August 2005 said that the person was at risk from an unhealthy diet. However, the person had no care plan around eating and drinking. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 19 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst there was evidence of personal care being provided appropriately, improved care planning in this area would promote the consistency and practice in accordance with people’s needs and preferences. 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. The management of medicines has improved and many requirements from the last inspection have been actioned. Some further work is needed to complete some of these and to make sure medicines are managed safely. EVIDENCE: As mentioned, care plans around the support that people needed with personal care were poor or non-existent. Staff described providing personal care in accordance with people’s needs and preferences and demonstrated awareness of issues around privacy and dignity. However, care planning in this area needs to improve. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 20 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 as far as possible. This was a requirement in the last report with a deadline of 30/06/06. During the inspection staff confirmed that these had not yet been written. This was therefore unlikely to be met by the deadline. In the last report it was suggested that the team look into adopting health action planning. The manager said that this was still being researched, with a view to adapting the format to better suit people with mental health conditions rather than a learning disability. Another comment was made in the last report about healthcare appointments being included as part of daily notes (as well as being recorded in the diary), rather than having a separate recording format. This system remained in place, making it difficult to quickly establish when service users had most recently had routine healthcare appointments. Such a system increases the potential for some routine healthcare to ‘slip through the net’, although direct evidence of this happening was not found during this or the last inspection. Many homes have a separate recording format for different healthcare appointments so that this information can be easily accessed. Correspondence indicated that people living in the home were receiving appropriate specialist healthcare services such as psychiatric reviews. However, as noted, an issue relating to one recently admitted person’s care has still not been resolved. This appeared to be posing obstacles to the person receiving other forms of specialist input from members of the local Community Learning Disability Team. Medicine storage arrangements have improved since the last inspection. Medicines seen were all ‘in date’. Care is needed to always segregate medicines for external use from those for internal use. Revised medication procedures were not seen on any unit – staff need clear guidance about the manner in which the home expects medicines to be dealt with. The manager said staff training about medication was being developed. Residents are able to give verbal consent to take medicines before each dose. A way of recording consent in the care plan is needed and was discussed. A homely remedies protocol is still needed. The manager said he had discussed this with doctors and the pharmacist. Various options to develop protocols were discussed. A number of products are in stock as homely remedies - some of these may not be appropriate for all residents. Records of giving these could be improved – ‘cough mixture’ is not sufficient information about what a resident has taken. Records of medicines brought into the home are generally filled in. A few medicines were missed and homely remedies received were not recorded. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 21 When residents are given medicines for leave periods a record of what is taken from the home and subsequently returned is needed. There are arrangements to correctly dispose of unwanted medicines and a special record book is used. Two nurses should sign each record when medicines are put in the disposal bin and these records attached to the consignment note from the contractor and kept in the home. Records of medicines given to residents have improved. Some charts did not have a second signature to confirm a check that medicine details were written accurately. One chart was seen indicating a dose of up to 8mg in 24 hours whereas the prescription and labelled medicine said 4mg in 24 hours. Latin abbreviations for instructions were less evident but still used on some records – use of English directions is clearer and safer. A second check may have identified points such as these. Staff are supposed to complete an audit count of medicines each week but this is not done. Use of some available records allowed limited checks of medicines remaining in stock. Some were correct but there were a few examples where records and remaining stock did not agree. This could indicate inaccurate records or medicines not given correctly. Medicine containers are not dated when opened although the action plan says this is done. This can also be a useful way to audit correct medicine use as well as making sure they are not used beyond the recommended shelf life. Some action has been taken to make more information available to staff about the use of medicines when prescribed ‘as required’ for particular residents. Further improvements could be made and were discussed with the manager to make sure that such medicines are given to residents in a consistent way according to defined needs. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 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. There are serious shortfalls in arrangements for protecting service users from harm and abuse, placing service users at significant risk. EVIDENCE: In the last report a requirement was made to make certain amendments to the complaints procedure and to give copies to service users (with a deadline of the end of June 2006). The procedure had been updated but the manager said that this had not been distributed to service users. He reported that people regularly approached him to raise issues but that these were generally resolved informally. The accessibility of the complaints procedure for some service uses was discussed. The team should consider this issue and make any necessary changes to the format in respect of different people’s needs. The updated procedure also needs to be distributed around the units since copies in the policies and procedures files were outdated. Some service users expressed confidence about raising issues, though others indicated that they were less confident about doing this. The pre-inspection questionnaire indicated that no formal complaints had been made to the home in the last year. Some staff reported that service users had made complaints Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 23 about various issues to the management in the last 12 months, and suggested that these should have been handled formally. A complaints file in the main office had not had an entry since 2004. The manager confirmed that nothing had been formally logged as a complaint since then. In view of information from some staff the management team may need to review at what point an issue is treated as a complaint and recorded as such in order to provide a clear log of complaints received and actions taken. The home has a whistle blowing procedure. However, documentation and discussion with staff indicated that over the past twelve months several staff members had raised concerns with the manager verbally or in writing but had not had a satisfactory response or, in some cases, no response at all. Discussion with staff along with documentation viewed suggested a profound lack of confidence in the procedures for raising concerns and for these being promptly investigated and addressed where appropriate. Evidence has been received by CSCI of the organisation taking necessary steps to investigate allegations of misconduct but there is also evidence of earlier concerns about the same issues not being appropriately handled. It is essential that service users, staff and others have confidence in procedures and practices around adult protection, complaints and whistle blowing. Acute incident sheets and other documentation provided descriptions of events which, in some cases, should have been reported to CSCI under Regulation 37. Examples included an incident when a service user had made an allegation about inappropriate behaviour from another service user, and a person recently absconding from the home. It was relayed to the manager that the Commission has only received one notification since the last inspection in March 2006. The manager expressed surprise at this, indicating that a system was now in place to ensure that notifications were made when necessary. Regarding the above allegation, the manager described how this had precipitated a service user moving to another unit. However, the allegation was not reported to CSCI, senior staff within Stepping Stones nor the local Adults at Risk team. The manager expressed concerns around the person’s confidentiality. However, in some cases it must be explained to a service user that particular information needs to be passed on through appropriate channels in line with adult protection and legal responsibilities. The only record of the allegation appeared to be in the person’s daily notes. The manager said that he had approached the service user to discuss the allegation afterwards but that he had not recorded this. He said that the person had not been informed of their right to contact the police if they so wished. At the point of the discussion 10 days had elapsed but there had been no further attempt to formally investigate the allegation nor to offer the person any counselling. The manager said that a psychology assistant had been contacted to investigate the allegation but it was not clear when this would Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 24 take place. A subsequent update indicated that this had taken place on June 27th and that follow-up interviews would take place. Records clearly showed that the person implicated in the incident had a history which highlighted significant risks to other people in this area. The allegation suggests that the home may have failed in its duty of care to protect a vulnerable service user. Staff also reported that other service users had made claims about bullying and intimidation. One person was reported to have said that it was better to be hugged than hit. This issue links to comments made in other sections about care planning, risk assessment and staffing levels. Some staff also expressed concern about failing to meet the duty of care of the alleged perpetrator given that the risks were clearly identified prior to the person moving in. Clearly no risk assessment and management system can guarantee people’s safety at all times, but there was significant evidence that the home had not undertaken reasonable steps to protect service users, staff and the person themselves from known risks. Some staff in the unit to which the person had moved stated that they had been told there would be higher staffing levels following the person moving in. At the time of the inspection staffing levels were unchanged. The manager acknowledged that this had not yet happened, indicating that it would be addressed, though subsequently adding that it was still being considered whether higher staffing levels were necessary/appropriate. Within the unit no interim care plan or risk assessment was in evidence about how service users there would be protected from the same kind of incident recurring. Some new behaviour management guidelines were supplied to CSCI at the feedback meeting on June 30th 2006, written in conjunction with the psychologist. In the last report a requirement was made about the need for clear and comprehensive care plans/individual protocols on the management of challenging and high-risk behaviour (to include any planned physical intervention). However, selected files did not include such protocols even though acute incident sheets indicated that challenging behaviour and restrictive physical intervention occurred relatively frequently. For example, one person had a plan dated November 2003 about anxiety and aggression which listed six brief guidelines which included ‘use Studio three techniques if required’ without further clarification. The plan had not been amended since 2003 and the last review was recorded as December 2005. A separate file (described by staff as not current) included some more detailed guidance from 2002 with no evidence of review since then. Staff spoken with confirmed that new protocols had not been written. The deadline for this requirement was 31/07/06 but it appears that this is unlikely to be met for all service users where this may be relevant. The last report included a requirement to clearly record the nature of any physical intervention technique used. However, some acute incident sheets Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 25 viewed continued to state ‘used Studio three techniques to escort…to room’ and ‘studio three techniques had to be applied’. Many staff spoken with reported a trend towards reduced use of restrictive physical intervention and more skilled application of low arousal techniques. However, there were comments about low staffing levels and difficulties with activity provision leading to increased difficulties around the management of challenging behaviour. Service users spoken with described how staff helped them if they were anxious or upset, indicating that they were happy with the support offered. Some staff spoken with confirmed that the managers had told people not to use personal loyalty cards for transactions involving service users’ money (linked to a requirement in the last report). In one of the three units a house loyalty card was in use. Careful consideration will need to be given to how any benefits are fairly distributed. A better scenario is for each service user to have their own if they so wish. Some records of service users’ finances were checked. One person’s record indicated that there had been just four balance checks in a period of about two and a half months. The frequency of balance checks needs to be increased. There was evidence of balances being out on occasions. A note in a communication book stated that one balance was down by about £6 on 21/05/06. A note in one unit on 01/05/06 stated ‘no balances correct’. One person’s balance check for 22/06/06 said ‘£1.23 over’. As well as increasing the frequency of balance checks (ideally checking daily or after each transaction) all entries should be double signed and receipts should be numbered in order to more clearly cross reference to record sheets. One person’s cash tin had a substantial number of loose receipts dating back to 2004. Receipts should be archived over time and should also be subdivided to make auditing more straightforward (for example, by putting each month’s receipts into separate, labelled envelopes). Clear records held in the main office provided evidence of service users receiving their entitlements (including the weekly personal expenses allowance). Staff reported that theses financial records were audited sixmonthly. Following the last report the service was requested to supply a copy of any policy in existence about the employment of people who are related to each other. No response was received about this. Whilst the National Minimum Standards and Care Homes Regulations in no way prohibit the employment of people who are related, it is an area which require considerations and careful management, and many organisations put this into a framework by the creation of a policy. This may, for example, include issues around supervision, line management and working together. The rota for 24/06/06 suggested that in one of the three units two members of one family had worked together Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 26 throughout the day as the only support workers on shift, in one case overlapping at the end of the shift with another family member. Whilst in no way singling out the people concerned or suggesting that practice on the day was in question, it is standard procedure in care settings to avoid this kind of scenario. The service is required to write and apply a policy covering issues around the management, supervision and working patterns of people who are related to each other. One file checked included descriptions and records of the person’s behaviours in terms of red, amber and green. The indicators for each had last been reviewed in May 2005, though appeared never to have been changed since being written in August 2002. The mood observation charts for 2006 indicated that the person had shown ‘green’ behaviours almost invariably during the year. However, when checked against acute incident charts for 2006 four occasions when serious incidents of challenging behaviour had occurred were still noted as ‘green’ on the recording chart, calling into question the accuracy (and purpose) or this record. In the feedback meeting on June 30th 2006 the manager said that this recording format were being phased out. A recommendation was made in the last report for all staff to have training in the protection of vulnerable adults/prevention of abuse. Training records indicated that this had not been taken forward and that training in this area was not prioritised (although it is touched upon during induction). In view of the findings above this is now required. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 27 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is significant scope to improve the environment in order to make the home a more pleasant place to live and work. A clean and hygienic environment is generally maintained, promoting service users’ health and wellbeing. EVIDENCE: All communal areas were checked, and some service users showed their rooms. The general standard of the environment was seen to be adequate, with reasonable decoration and furnishings and a good standard of cleanliness. The following observations were made: Winston: The ground floor toilet continues to generate ‘hot’ water at too cool a temperature (recorded as 21°C on 14/05/06). This requirement is repeated. A requirement was made to replace a stained/worn basin in the kitchen. The deadline for this was 31/07/06 and had therefore not expired. The work had not yet been done. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 28 Nimrod: The atmosphere remains very smoky in the dining room (the designated smoking area), despite the use of an extractor fan (other units were also smoky, although the use of a dedicated smoking room helps to reduce this to some extent). Dorabella: The carpet on the stairway was very stained and needs replacing. Staff complained that the room is small and becomes very hot. They suggested that an extractor hood could be fitted over the hobs and that the walls to the pantry could be knocked through to enlarge the space available. A requirement about replacing a cracked lower freezer shelf had not been met. Daycare: Staff explained that the kitchen was due to be refitted. In the meantime action must be taken to replace broken/missing shelves in the fridge since food was being stored unhygienically. More generally, many areas of the home had décor which was tired and worn. For example, many of the corridors are painted in a uniform, faded yellow and would benefit from being redecorated. Some toilets and bathrooms had marked walls and areas of flaking paint. A plan should be drawn up for the complete redecoration and refurbishment of such areas, including consultation with service users. A requirement was made in the last report to provide suitable storage facilities for staff. The deadline for this had not yet expired. This related to there being no secure storage facilities for personal belongings, resulting in people leaving things loose in the offices. 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. The home is set is attractive grounds. Observation, along with discussion with staff and service users indicated that good use was made of the gardens. For example, service users were preparing for a sports day later in the month. In the last report a suggestion was made to consider employing a cleaner in the units. It has been proposed that this would contradict independent living skills principles and would make the units less homely. This principle is accepted and supported. However, staff reported that in reality they did the vast majority of cleaning and that, given the short staffing, this was further compromising the time that they had to work directly with service users. This could also be addressed by increasing general staffing levels. A recommendation had been made about providing a second washing machine in Winston. In response to this it was stated that there was no assessed need for additional provision. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 29 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 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. Appropriate systems are in place around recruitment and selection helping to protect service users. Shortfalls in staff training and supervision could significantly compromise the quality of care provided. EVIDENCE: Job descriptions were checked. Whilst there were examples for team leaders, support workers and the manager no descriptions could be found for the deputy manager or daycare roles. The service should consider creating these in order to give more clarity to the roles and responsibilities of these posts. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 30 According to information supplied in the pre-inspection questionnaire 8 staff had NVQ level 2 or equivalent out of 25 care staff (32 ). Although it is accepted that there are a number of new care staff, progress towards getting at least 50 of the care staff qualified to this level should be accelerated. It was agreed that in this setting it may be more appropriate for staff to take the certificate in mental health. As indicated elsewhere in the report, there is evidence that some staff have development needs in areas such as care planning and risk assessment & management. See also comments in other parts of the report about specific training needs. The administrator said that all staff receive copies of the GSCC code of practice and an employee handbook. Service users were generally positive about the staff team. Comments included that they were ‘polite’ and ‘nice’. Comment cards and other feedback from health & social care professionals also provided much positive feedback. For example, people praised the skills of the team and the support offered to become more independent and indicated that staff seemed to have relevant training and knowledge. Staff spoken with were able to describe people’s needs and specialist conditions and the impacts that these had on their daily living. Staff were observed interacting with service users in a warm, positive and respectful manner. Some care workers indicated that staffing levels were generally adequate but became very stretched when there was an incident of challenging behaviour or if somebody was sick. People commented positively on a recent recruitment drive leading to the employment of several new support workers. Comments have been made elsewhere in the report about overall staffing levels in terms of: • • • Ability to provide appropriate activities, including on an individual basis and in the community. Demands on the staff team to undertake roles such as cleaning and cooking which may involve work with service users but which, in many cases, take them away from direct care and support work. Identified risk issues in particular units indicating that higher than current ratios of staff to service users may be required. In addition, the manager and staff reported that there is still significant difficulty recruiting permanent team leaders, resulting in two of the units being covered by a single team leader. This has implications for day-to-day management, monitoring and supervision and for areas such as care planning and risk assessment. The shortage also means that the manager and deputy Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 31 continue to step into the team leader role on a frequent basis, taking them away from management tasks. Agency staff were being used to cover some of the shortfall. A requirement had been made about adequate staffing levels in the last report with a deadline of 31/03/06. A staffing levels assessment conducted in relation to service users’ assessed needs may be a useful step forward. Three staffing files were checked. These appeared to be in order. In one case some omissions were explained directly by the personnel officer who said that once all paperwork was in place it would be forwarded to the home. It was pointed out that there is repetition involved in routinely undertaking PoVa-First checks on all staff who have the same check done as part of their CRB and only start once the latter is in place. There was evidence that the service has started asking for two professional references rather than one personal and one professional. Training records for four staff were checked in more detail. These highlighted significant shortfalls in the provision of core training including fire safety, first aid, food hygiene and moving & handling. No records of any training could be found for one person who had worked in the home for several years, albeit on and off. Mandatory training must be brought up to date for all staff as far as possible. These lapses suggest a failure in the system for identifying and meeting training needs. A requirement had been made in the last report about this with a deadline of 31/07/06. This is unlikely to be met. Despite the above, staff were generally positive about the training provided by the organisation, citing regular time being set aside on the rota for training. Staff described recently attending courses about values & diversity, autism and communication. A list of courses available provided evidence that staff can access a wide range of appropriate training. Comments are made elsewhere in the report about specific areas where staff may benefit from training. The requirement about training made in the last report included that staff must have refresher training in the management of challenging behaviour (currently provided by Studio III) at suitable intervals. Records indicated that this was not happening. For example, one person’s record indicated that they last received any input in this area in 1999. Given the situations that staff have to manage it is essential that they receive regular updates in this. A recommendation from the last inspection for all staff to have training in record/report writing is repeated as records showed that few staff had done this. Such training is regarded as general good practice in any care setting. The service has an induction format which is to be worked through in conjunction with their line manager. Newer support staff spoken with were positive about their inductions but had seen this format. Nominated staff in Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 32 each of the units are assigned to mentor new care workers. More senior staff identified shortfalls in the induction process which will be considered in more detail in future inspections. The staff meeting file was checked in one of the units. The last record of a meeting was 20/07/05. A staff member commented that meetings had been regular until the departure of a team leader resulted in one person overseeing two units. A recommendation was made in the last report to reintroduce regular staff meetings. This is repeated. Staff reported patchy experiences with formal, recorded supervision. Some indicated that they were now receiving regular supervision but other that they were not. For example, one person said that they had not been formally supervised since January 2006. The requirement from the last report is therefore repeated. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 33 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is not well run, with resulting negative impacts of the quality of care provided and service users’ safety and wellbeing. Reasonable quality assurance systems are in place, providing a framework for monitoring and improving the quality of care. Basic health and safety shortfalls present avoidable risks to service users and staff. EVIDENCE: Staff reported that the manager was approachable. However, as noted in the report, some staff reported that expressions of concern were not always handled in an appropriate and timely way. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 34 The shortfalls identified in the rest of the report provide evidence of significant deficits in the home’s management. The manager acknowledged this, saying that the staffing situation was having a major impact, particularly since he was having to regularly act as team leader (such as on 23/06/06 during the inspection). In recognition of the difficulties with the management of the home the organisation conducted its own investigation into the situation, resulting in a new supervision and support mechanism for the registered manager. The manager reported that he was taking the Registered Manager’s Award and hoped to have completed this by the end of 2006. The home has achieved ISO 9000 certification. The last external (annual) audit by relating to this took place in September 2005 and resulted in no issues being raised. As part of quality assurance a new manual has been circulated to the units, including new procedures in a number of key areas. The administrator has a role in the home’s quality assurance strategy and said that a full review of the home’s policies and procedures was planned. It was agreed that many of the home’s policies and procedures are out of date, and that they should link more closely to the policies in the QA manual. It was reported that there is a monthly QA audit. An example of this was tracked, and evidence of the units implementing the outcome of the audit was seen. The home has a policy of conducting an annual survey of stakeholders (service users, family and professionals involved in service users’ care). Some examples from 2006 were seen. During the last inspection the manager said that the results of these surveys are discussed at monthly management meetings. However, no summary of findings is compiled. It was suggested that this be done since. For example, all respondents in the 2006 service users’ survey said that they did not have a copy of the home’s complaints procedure but this had not subsequently been noted in any summary of findings nor had it been addressed. A summary report and actions arising would help to make the QA process more of a loop of continuous improvement rather than a series of exercises in isolation. Regulation 26 reports are being supplied regularly to CSCI. Staff reported that these are unannounced. Whilst a number of quality assurance systems are in place the shortfalls identified in this report suggest that there are areas where the QA process is not sufficiently robust, thorough and wide ranging. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 35 Staff spoken with felt that the home was generally a safe place to work. They described regular health and safety audits taking place. As noted earlier in the report there are ongoing issues with risk assessment and the lack of effective protocols for the management of challenging behaviour. This increases risks for service users and staff. Whilst checking the environment some potentially hazardous chemicals were found to be accessible in toilets and also in laundries left unattended with the door propped open. These included products marked as irritants. The manager confirmed that the policy was for these to be locked away at all times. This was a finding from the last inspection. The requirement is repeated. Fire doors in various parts of the home were found to be propped open. This included kitchen doors (for example in Nimrod and in daycare) and laundries (for example, in Dorabella). These must either be closed or automatic closing devices linked to the fire alarms fitted. This issue had been highlighted in a health and safety audit conducted in January 2006. The manager and deputy said that they had reminded staff about this. The fire risk assessment was not checked on this occasion. However, as noted, some staff were not receiving fire safety training at suitable intervals according to records checked. There were also shortfalls in other areas of mandatory training, which has implications for the health and safety of staff and service users. A fire safety checklist was seen in each of the units. A memo stated that this was to be completed monthly, although in one unit this had not been completed since February 2006. Fire log books in some units were satisfactory. However, in Winston the last check by staff on emergency lighting was noted as 16/02/06 (although there was an external servicing in May 2006). Since April 2006 alarms were noted as being tested on 06/04/06, 18/04/06 and 24/5/06. This frequency of testing is inadequate. This was the subject of a requirement in the last report (deadline 31/03/06). That requirements about fire precautions and hazardous chemicals are having to be repeated suggests sustained failures in basic areas, with direct impacts on people’s health and safety. In the last inspection staff in two units raised concerns about summoning help if required, such as during an incident of challenging behaviour. 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 had been issued with walkie-talkies but 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 Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 36 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. In response to this issue being raised again in the draft report it was stated that walkie-talkies remained the most effective method of summoning help. This issue will be revisited in future inspections. Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 37 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 1 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 3 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 x 1 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 x 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 x 1 x 2 x x 1 x Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 38 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 (1) & (2) Requirement Ensure that care plans describe how service users’ needs in respect of health and welfare are to be met and that 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 Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 39 Timescale for action 31/07/06 2 YA6 18(1)a & (c)(i) 31/07/06 3 YA7 12(1,2&3) 15 Sch.3.3 q 31/07/06 4 YA9 12(1)13(4) 30/06/06 5 YA12 12(1)a 16(2)m&n 6 YA18 12(4)a 7 YA20 13 8 YA20 13 9 YA20 13 10 YA20 13 11 YA22 22 (5) update risk assessments as required. Provide appropriate activities for all service users based on their individual needs and interests. 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. Procedures and use of homely remedies to be reviewed as indicated in the inspection report of 02/02/06. Previous timescale 01/03/06 not fully met. The medicine policy and procedures to be reviewed as indicated in the inspection report of 02/02/06. All staff to be made aware of this and monitored in their adherence and understanding of it. Previous timescale 01/05/06 not fully met. Regular audit counts must be in place and documented to demonstrate the correct use and recording of medicines. Previous timescale 01/04/06 not fully met. Protocols describing the use of any medicine prescribed ‘as required’ must be written and used. Previous timescale 01/03/06 not fully met. Supply a copy of the DS0000016539.V301979.R01.S.doc 30/09/06 30/06/06 15/08/06 15/08/06 15/08/06 15/08/06 31/07/06 Page 40 Pfera Hall Version 5.2 12 YA23 9 (2) 12 (1) a & b & (5) 13 (6) 22 (3) 13 YA23 37 14 YA23 12(1) 13(4)&(7) 15 15 YA23 13 (8) 16 YA23 12 (1) a 13 (6) 17 YA23 12 (1) a 12 (5) 13 (6) updated complaints procedure to each service user. Where there is suspicion or evidence of abuse or neglect, or where any other concerns about care practices or the ability of the service to meet people’s needs are raised, ensure that this is appropriately recorded, investigated and acted upon without delay. Ensure that CSCI is promptly notified of events as defined in Regulation 37. 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. Deadline of 31/03/06 not met. Checks service users’ cash balances against running records at suitable intervals (ideally daily or after each transaction). Write and apply a policy covering issues around the management, supervision and working patterns of people who are related to each other. Supply a copy to CSCI. 31/07/06 31/07/06 31/07/06 31/07/06 31/07/06 31/08/06 Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 41 18 YA23 13 (6) 19 20 YA24 YA24 23 (2) d 13 (3) 23 (2) j 21 YA24 13 (3) 23 (2) b & d 23 (3) a 18 (1) a 22 23 YA24 YA33 24 YA35 12 13 18 23 (1) (3) & (4) (1) c (i) (4) Training must be provided for all staff in the protection of vulnerable adults/prevention of abuse. Replace the stained carpet on the stairs in Dorabella. • Replace the missing shelves in the fridge in the daycare area. • The ground floor toilet in Winston was producing hot water at too cool a temperature. This needs to be rectified. Timescale of 31/03/06 not met. • The lowest shelf in one freezer in Dorabella was cracked and requires replacement. Timescale of 30/04/06 not met. The hand basin in the kitchen in Winston is very stained and worn and requires replacement. Provide suitable storage facilities for staff. Ensure that all times there are enough staff working in the home to meet service users’ needs in respect of health and welfare (at both support worker and team leader level). Timescale of 31/03/06 not met. All staff must receive training appropriate to the work they perform. This must include refresher training in the management of DS0000016539.V301979.R01.S.doc 31/12/06 31/10/06 30/09/06 31/07/06 31/07/06 31/08/06 31/07/06 Pfera Hall Version 5.2 Page 42 25 YA36 18(2) 26 YA42 23 (4) c 27 YA42 12 (1) 13 (4) 12 (1) 13 (4) 23 (4) 28 YA42 challenging behaviour at suitable intervals. All staff must be appropriately supervised. Timescale of 30/04/06 not fully met. Fire alarms and emergency lighting must be tested at suitable intervals. Timescale of 31/03/06 not met. Ensure that hazardous chemicals are locked away if necessary. Timescale of 31/03/06 not met. Fire doors must either be kept closed or automatic closing devices linked to the fire alarms fitted. They must not be propped open. 30/09/06 31/07/06 31/07/06 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA2 Good Practice Recommendations Needs assessments conducted by Pfera Hall staff with people referred to the service should be recorded in full and stored in the person’s file with other background and assessment material. Note in the admissions procedure that the service will confirm in writing to new service users being admitted that the home is suitable for meeting their needs in respect of health and welfare. Rewrite front sheets in service users’ files where they are becoming tatty and hard to read, and/or have amendments attached on loose pieces of paper. • Revise the care planning format to use positive language rather than the heading ‘problem’. 2 YA2 3 4 YA6 YA6 Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 43 • 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 implementing a more person-centred care planning system in the home, adapting this for people without a learning disability as appropriate. 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. • • 5 YA7 6 YA12 • Aim to type all care plans. Where there is an assessed need to promote a structured routine (which may include retiring for the night at particular times) this should form part of individuals’ agreed care plans. Systematic records should be kept by daycare staff of the activity sessions, linked to people’s care plans and identified needs, interests and goals. Ensure that daily records in the units give a clear indication of activities/how the person spent their time. As part of overall care planning review the extent to which daycare timetables reflect people’s assessed, recorded needs, preferences and interests. The specialist training needs of daycare staff should be identified and measures put in place to meet these learning needs in accordance with the specialist nature of the role. Note service users’ preferred form of address on their files. Provide training for all staff in promoting service users’ rights/empowerment. 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. 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 7 8 9 YA16 YA16 YA18 10 YA19 Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 44 11 12 YA20 YA22 13 14 15 YA23 YA23 YA23 16 YA23 living in the home). Service users’ consent to medication to be obtained and recorded in individual plans. • The accessibility of the complaints procedure for some service uses should be considered, and any necessary changes to the format made in respect of different people’s needs. • Following distribution of the updated complaints procedure talk through with each person about their right to complain formally and how they go about this should they so wish. • The manager and senior staff should review at what point an issue is treated as a complaint and recorded as such in order to provide a clear log of complaints received and actions taken. Offer service users who have been subject to inappropriate behaviour counselling or other support appropriate to their needs. Remind service users of their right to report allegations of abuse and harassment to the police if they so wish. Careful consideration will need to be given to how any benefits from loyalty cards are fairly distributed. Consider the scope for each service user to have their own if they would like one. All entries in service users’ financial records should be double signed and receipts should be numbered in order to more clearly cross reference to record sheets. Receipts should be archived over time and should also be subdivided to make auditing more straightforward (for example, by putting each month’s receipts into separate, labelled envelopes). Where systems are in place for recording patterns of behaviour in terms of ‘red, amber or green’ ensure that the indicators are clearly defined, regularly reviewed and updated when necessary. Review the overall accuracy and purpose of the behaviour recording charts as noted in the text. Continue to consider ways of reducing the smoky atmosphere throughout the home and the risk of passive smoking. Ideally there should be provision for people to smoke in a location which does not then result in a smoky atmosphere throughout the units. Consider how to make the kitchen in Dorabella a cooler working environment. Consideration could also be given to enlarging the space available. Consider whether a staff room should be provided. DS0000016539.V301979.R01.S.doc Version 5.2 Page 45 17 YA23 18 YA24 19 20 Pfera Hall YA24 YA24 21 22 23 24 25 26 27 28 YA24 YA30 YA31 YA32 YA33 YA35 YA35 YA39 Consult with service users and generate a plan for the redecoration and refurbishment of all communal areas where décor is tired and worn. Consider employing a cleaner for the communal areas in the three units. Create job descriptions for the deputy manager and daycare roles. Progress towards getting at least 50 of the care staff qualified to NVQ level 2 or setting-specific equivalent should be accelerated. Reintroduce regular staff meetings (at least six per year). Training in record/report writing should be provided for all staff. Ensure that new staff work through the set induction format. Undertake a full review of the home’s policies and procedures, including creating clearer links between the policies and procedures file and the quality assurance manual. Do a summary report of the findings from stakeholder surveys and list the actions arising. Ensure that fire safety audits/checklists take place at the frequency stipulated by internal policy. 29 YA42 Pfera Hall DS0000016539.V301979.R01.S.doc Version 5.2 Page 46 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. 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