Inspection on 27/11/07 for Pfera Hall

This inspection was carried out on 27th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pfera Hall 16/12/08

Pfera Hall 05/12/06

Pfera Hall 22/06/06

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 Bromsberrow Road Redmarley Gloucestershire GL19 3JU Lead Inspector Mr Adam Parker Key Unannounced Inspection 27th November & 5th December 2007 09:15 Pfera Hall DS0000016539.V348976.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.V348976.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.V348976.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pfera Hall Address Bromsberrow Road Redmarley Gloucestershire GL19 3JU 01531 650880 01531 650833 lee@pferahall.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Stones Holdings Limited 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.V348976.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with Nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following categories: Learning disability (Code LD) Mental disorder excluding learning disability or dementia (MD) The maximum number of service users who can be accommodated is 19. 12th January 2007 2. Date of last inspection Brief Description of the Service: Pfera Hall is registered to provide care with nursing for up to 19 people 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, though at the time of writing ‘Dorabella’ was empty. Each unit 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 home has several vehicles in order that service users can access the wider community. The standard fee for the service is £2773.80, but there is negotiation with funding authorities depending on the needs of each person admitted to the service and the input they require. The Service Users Guide includes information about what is included in the fees. 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.V348976.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The visit to the service included a tour of the premises, examination of documentation and medication systems and discussions with a person using the service, staff and management. The inspector was joined on the first day of the inspection visit by an ‘expert by experience’. A person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. As well as a visit to the service over two days, comment cards were received from seven relatives of people who use the service and four from health and social care professionals. An (Annual Quality Assurance Assessment) AQAA was completed and provided for the inspection. What the service does well: What has improved since the last inspection? There have been improvements in the process and documentation around assessing and admitting people to the home as well as in care planning, risk assessment and management. Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 6 Overall the medication systems are better although there is still a small amount of work to be done with these. Improvements have been made to the information and recording of any complaints and concerns and in some areas that will help safeguard people using the service from possible harm or abuse. There have been some improvements to the environment although work is still needed in some areas. Quality assurance has benefited from the introduction of clinical governance meetings. Staff are receiving more supervision sessions following a reorganisation of how this is carried out. 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. The summary of this inspection report can be made available in other formats on request. Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 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.V348976.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service receive comprehensive assessments prior to admission to ensure that their needs can be met before they are admitted to the home. EVIDENCE: Admissions are arranged through an admissions manager who is based in another service that the provider operates. This is a new development since the previous inspection. In addition a new pre-admission document is now in use that is more comprehensive than previous documents. Full information had been obtained regarding one person recently admitted to the service. The manager has also been involved in some assessments with visits to the person prior to admission. It was noted that some older admission forms had now been produced in a typed format following a recommendation at the previous inspection. Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There has been an improvement in the areas of care planning and risk assessment and management, this together with better documentation on any restrictions on people using the service gives staff clearer information on how needs can be met as well promoting their safety and support decisions they make. EVIDENCE: Plans for the care and support of three people using the service were looked at. It was noted that these had been typed and one area of the plan had been titled ‘need’ where on previous inspections this area had been titled as ‘problem’. A staff member had signed the plans and there was space for the person using the service to sign. This had not yet been achieved with the examples looked at although in the case of one person who had refused to be involved with the care plan document a separate record had been made of discussions with their key worker about their needs. Care plans included a Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 10 space for evaluation on the reverse and where care plans had been in place long enough there was evidence of monthly review. Care plans dealt with needs such as personal hygiene, trips out of the home, visual hallucinations and eating and weight. It was noted that one plan addressed the need for the person to develop more independence in meeting one particular need. Copies of Care Programme Approach documentation were seen which clearly described the role of the home as well as that of health and social care professionals. The ‘expert’ noted, “The two people who could respond knew their care plans, the names of their social and key workers and their consultant.” Team leaders are responsible for writing care plans, it was reported that these are audited and care planning training has been incorporated into record keeping training provided to staff. A number of restrictions and limitations on choice were in place but these had been clearly documented. With one person a document had been completed regarding staff keeping the person’s cigarettes and allowing them one to smoke each hour. Other documented areas of restriction were access to money and whether the person had a key to their individual room or not. One document lacked the reasons why a person had not been given a key to their room and this was mentioned to the acting manager during the inspection visit. A Service User forum is planned for 2008 where people using the service will have the opportunity to speak to someone from outside the service about issues in the home. Risk management plans were in place following assessment. One such plan dealt with the person’s risk to themselves and to others and was detailed, specific and individualised. The plan detailed past history and factors that may increase the risk and were clearly evidence based. Staff had signed to state that they had read and understood care plans and risk management documents. Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,14,16 & 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are able to take part in appropriate activities outside of the home, have some links with the local community and pursue a range of leisure interests in order to enhance their lifestyle. EVIDENCE: One person using the service was spoken to and described his desire to find some work outside of the home. The possibility of voluntary work was being looked at. The AQAA document received from the home reported, “ In the past we have supported service users in going to college and work placements according to their wishes.” Some people using the service have taken part in quilt making and stone carving through a course provided by a local college. Photographic evidence of stone carving and the finished article where seen during the inspection visit. Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 12 The acting manager described how people using the service were able to have some links with the local community such as use of the local post office and public house. In addition a delivery of Christmas cards to residents of the village was being planned. Flags made in the home for Remembrance Day had been displayed in the local church. A range of leisure activities are provided for people using the service including swimming, horse riding and golf on a local range that was popular. In addition walks in the surrounding countryside and visits to local towns and cities were also made. The day care service, as well as providing a range of activities for people enables them to develop skills such as cooking, planning and budgeting for meals and shopping. After observing people using the day care service the expert who contributed to the inspection commented ”I was delighted to see her given an audio book with headphones by the art therapist and her face became animated as she listened.” One person using the service also commented that it was “great and there was a lot to do.” The expert was also “very impressed with the activity supervisor who explained they took an individualistic approach to each client to fulfil their needs, and I could really see that in action.” A record is made of whether people attended activity sessions or not. There are plans for the day care service to move from the home to another site. People using the service were able to maintain relationships with friends and family members and a number of examples were reported including one where a male using the service was able to have meetings with their girlfriend. One person had a care plan regarding maintaining contact with family and friends. Comments on surveys received from relatives of people using the service confirmed how they were able to maintain contact and one commented how the person was able to visit their family once a month. It was noted that peoples’ preferred form of address had been recorded. Some people hold a key to their rooms although where this is not the case the reasons are generally recorded as noted elsewhere in this report. Staff were observed interacting with service users, not exclusively with each other. The home has set menus that change on a six weekly basis although these are usually altered through consultation with people about their personal choices. At times this extends to ‘takeaway’ meals. Forms for people to provide feedback about the meals provided in a pictorial format had been prepared ready for use. It was reported that fresh fruit and vegetables are delivered three times a week and one such delivery was seen in the kitchen in Winston. Fresh fruit was available in communal rooms. An improvement was noted in the recording of dietary intake with more detail being included. Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is still some scope to improve systems for monitoring and recording people’s access to healthcare services as well as ensuring that certain actions in respect of monitoring are carried out as planned. However on the whole there has been an improvement in medication systems and in recording peoples’ preferences about personal and health care as a way of ensuring that people receive the care that they need. EVIDENCE: A number of care plans were looked at for people who needed degrees of personal care or support. With one of these the person’s preference for the gender of the staff member providing personal care had been recorded. Files for people using the service contained evidence of healthcare needs being met through hospital appointments and specialist medical advice. One person had a reluctance to see and be examined by healthcare professionals and this was recorded with interventions on an appropriate care plan. In addition a care Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 14 plan was in place to manage personal hygiene and in particular continence issue. Actions included the monitoring of fluid intake which was taking place but also the monitoring of incontinence episodes with the view to establishing if there was a pattern. Although a form had been produced for this, it was not in use at the time of the inspection visit. People’s weights were being checked and recorded where the need for this had been identified. At previous inspections it was recommended that the team look into adopting health action planning. This should now be considered for people with a learning disability, with consideration being given to whether it might also be a useful tool for people without a learning disability. There is some need for a system for recording healthcare appointments and the outcomes of these separate to daily recording to provide an easier overview and help to plan for any future appointments. Medication was stored securely with storage temperatures being monitored and recorded. Some bottles of liquid medication had been used without the date of opening being recorded on the bottle. There were lists of homely remedies in use in the home that had been agreed by General Practitioners. Consent forms for the administration of medication had been completed and had been signed by people using the service, these were included with the medication administration charts. This acknowledged that the medication is the person’s medication. Handwritten entries for medication administration had been signed and checked in some but not all cases. One person had a care plan which included interventions for them to be educated about side effects with a view to being able to report these to staff. This plan also described how medication prescribed on a PRN or ‘as required’ basis may be given. Another care plan described how a reduction in medication would be managed. Survey forms received from health and social care professionals indicated that the medication for people using the service was managed appropriately in the home. A recommendation made at the previous inspection by a pharmacist from the Commission regarding amendments to home’s medication policy have not been checked in full at this inspection although it is noted that the policy was dated November 2007. It was noted that recent copies of the British National Formulary (BNF) for medication were available in the home. Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Systems are in places that enable complaints and concerns to be raised by people using the service or on their behalf with further improvements made to safeguard people from possible harm or abuse. EVIDENCE: The complaints procedure was on display on notice boards in a number of locations in the home. In addition the complaints procedure was seen in a new symbol format. The home has a log for recording complaints; one complaint had been received from the parents of a person using the service, this related to arrangements for ordering medication. The acting manager described how improvements had been made to medication ordering since the complaint was received. A response in writing had been provided to the complainant. Related documents had been appropriately completed and signed. Out of seven survey forms received from relatives of people using the service, five indicated that they knew how to make a complaint. All staff attend ‘in-house’ training in protecting vulnerable adults and a number of staff have attended training in protecting vulnerable adults provided by the local authority. Information from the local authority in the form of the ‘alerter’s guide’ was on display in the home. The enhanced training for management should be given consideration for the future. Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 16 There had been a delay in reporting to the Commission of an alleged incident of abuse that took place outside of the home in June 2007. This should have been reported without delay under regulation 37. However more recently any incidents that are reportable under this regulation have been reported promptly. Where money is held in safekeeping by the home on behalf of people using the service, cash balances are being checked against records on a regular basis. As clear risk management plan was seen to be in place for one person using the service who exhibited aggressive behaviour at times. The plan gave examples of warning signs and had been reviewed on a monthly basis. In addition staff have received refresher training in the management of challenging behaviour. A recommendation made at the previous inspection regarding the policy about management of staff who are related to each other. As well as being signed and dated, this should also include reference to issues that may arise if a line manager is related to an employee, such as about not conducting their supervision meetings. The recommendation regarding this policy is repeated in this report. The acting manager stated how she intended to create a culture in the home where all staff felt able to report any concerns about practice. Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,27 & 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although generally well-maintained and clean, people using the service would benefit from some improvements to certain areas in the environment particularly toilets and bathrooms. In addition the home must work at managing the challenge of keeping some rooms in a clean and odour free state. EVIDENCE: A tour of the premises was undertaken. Communal areas and some individual rooms were looked at. Winston The kitchen had a new work surface and other work was taking place to repair damage to the wall caused by a water leak. It was noted that regular checks were being made and recorded on freezer and refrigerator temperatures and Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 18 food stored in the refrigerator was covered, labelled and dated. There were fresh vegetables stored in the kitchen. Communal areas were generally clean and consisted of a lounge with a television, a small lounge and a dining room. The laundry in Winston was clean but hand washing facilities in terms of soap and paper towels were lacking. One person’s bedroom was odorous on the first day of the inspection visit but when checked on the second day the situation had improved and some redecorating had also been done. Another room had no proper floor covering and was not in a clean state. This was discussed with the acting manager on the second day of the inspection and a plan is in place to deal with the situation that took into account the fluctuating mental health of the person living in the room. Another room looked at had problems with condensation on the windows and consequently the windowsills were marked with a black residue and in need of a clean. The shower room was looked at, it was reported that the floor was due for replacement. The washbasin had a crack near the plughole and needs replacement. One toilet was locked and out of use and was noted to be odorous. Nimrod Mops and buckets as well as some cleaning materials were now being stored in a recently constructed cupboard and not in the linen cupboard. One individual room was suffering from similar problems caused by condensation to the room noted above in Winston. There had been an improvement in one toilet where a new floor covering had been fitted and extended beyond the skirting board level that will enable a more pleasant and hygienic environment to be maintained. In the shower room there was damage to paint work on the skirting board level near the toilet. There was some damage to the bath panel in the bathroom, the shower room. Dorabella This unit is registered but not currently in use, a brief tour of the unit was undertaken. The day care unit was in use during the inspection visit although this had recently closed pending a move to an off-site facility it had been brought back into use again until the new facilities had been fully developed. There is a shelter at the side of the home for people who wish to smoke. Ample outside space is available in the grounds of the home. Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 & 36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Recruitment and selection procedures are robust ensuring that people using the service are safeguarded. Staff have access to a training programme that will equip them to meet the specific needs of people using the service. EVIDENCE: The ‘expert’ who contributed to the inspection commented that there was “a very respectful attitude from the staff towards the residents.” And “All staff were extremely helpful and willing to answer my questions and show me around.” The home is still working towards achieving 50 of its care staff (excluding registered nurses) with an NVQ level 2. A recommendation regarding this is repeated in this report. A comprehensive training programme is provided for staff in the form of a continuous professional development course. This includes areas relevant to the needs of people using the service such as managing challenging behaviour Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 20 (including refresher sessions), understanding learning disability and report writing and record keeping. The documents for a number of recently recruited members of staff were seen. All the required information had been obtained although at the inspection visit there was no evidence that the registration of nurses employed in the home had been verified with the Nursing and Midwifery Council. However following the inspection the home has supplied information that these checks were being carried out. Staff receive induction training using the LDAF (Learning Disability Awards Framework) as a basis for this. Preceptorship is also available for newly registered nurses who commence work at the home. Examples of records of staff supervision sessions were seen. The responsibility for carrying these out had been delegated to team leaders as well as involving the management of the home. Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Despite the resignation of the registered manager the home has been managed in the interests of people who use the service with an improvement in quality assurance. EVIDENCE: The registered manager had resigned the day before the first day of the inspection visit. It was later reported that this was by mutual agreement with the registered provider. An acting manager had been appointed supported by a deputy manager. The acting manager who is a registered mental health nurse was present for both days of the inspection visit. Since the last inspection there had been Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 22 changes to the ‘on-call’ management arrangements with this role being covered by a greater number of senior staff. The home has started to use clinical governance meetings as a way of looking at quality issues in the home. These meetings involve registered nurses although there are other meetings for team leaders and management. There were examples found during the inspection of how the clinical governance meetings have picked up on shortfalls and addressed these. There is also a plan for a quality assurance system to cover all the homes provided by the Stepping-Stones group. The acting manager described how she has attended staff handover meetings and walks through the home each day she works to keep in touch with any issues. An annual client satisfaction survey has been used as well as surveys from relatives of people using the service and health and social care professionals from funding authorities. Residents meetings are held to discuss issues about the service and living in a group. A residents’ forum is planned for 2008. Recent survey forms had been received and were awaiting an evaluation of the information on them. Staff have received training in safe working practices in first aid, food hygiene, manual handling, health and safety, risk assessment and fire safety. The home has ensured the servicing and maintenance of electrical and central heating systems and appliances. Cleaning materials were securely stored with no decanting from large to small containers evident. Evidence was seen of water temperatures being checked and recorded in individual rooms. Fire drills had been carried out and recorded although there was no evaluation of how successful these had been which was recommended at the previous inspection. At the previous inspection a recommendation was made regarding checks on vehicles. Records of these were seen although they had not been carried out daily as the policy suggested. It was reported that the policy was currently under review regarding the frequency of these checks. Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 3 X X 2 X Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA19 Regulation 12 (1) (a) & (b) 23 (2) (b) & (d) Requirement Timescale for action 31/01/08 2 YA27 Where actions are identified in care plans in respect of monitoring then these must be carried out and recorded. Ensure that all toilets, bathrooms 31/03/08 and shower rooms are kept in a well-maintained and clean state with any damage to fittings repaired so that they are accessible and useable by people using the service. 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 YA19 Good Practice Recommendations Improve monitoring and recording systems around healthcare and consider implementing the ‘health action planning’ format and framework (or an adapted version as suitable for the needs of each person living in the home). Ensure that creams and liquids are marked with the date of opening. Ensure that the practice of signing and checking and DS0000016539.V348976.R01.S.doc Version 5.2 Page 25 2 3 Pfera Hall YA20 YA20 4 YA23 5 6 7 8 9 YA23 YA24 YA30 YA32 YA42 signing hand written directions on medication administration charts is extended to all entries. As well as being signed and dated, the policy about the management of staff who are related to each other should include reference to issues that may arise if a line manager is related to an employee, such as about not conducting their supervision meetings. Give consideration to members of the management team attending the enhanced training in protecting vulnerable adults provided by the local authority. Work towards keeping certain individual rooms in a clean and odour free state. Provide hand-washing materials in the laundry in Winston. Continue progress towards getting at least 50 of the care staff qualified to NVQ level 2 in health and social care or a suitable equivalent. When fire drills are conducted keep a record of how they went/any issues arising, as part of the ongoing process of monitoring and improving safety in this area. Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Pfera Hall DS0000016539.V348976.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!