Inspection on 13/03/06 for REACH Sistine Manor

This inspection was carried out on 13th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

REACH Sistine Manor 10/07/08

REACH Sistine Manor 26/07/07

REACH Sistine Manor 15/09/06

REACH Sistine Manor 30/03/05

REACH Sistine Manor 12/11/04

REACH Sistine Manor 03/03/04

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 Sistine Manor Stoke Green Stoke Poges Bucks SL2 4HN Lead Inspector Mike Murphy Unannounced Inspection 13th March 2006 09:30 Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sistine Manor Address Stoke Green Stoke Poges Bucks SL2 4HN 01753 531869 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) REACH Limited Mrs Nasrin Saeedi Mrs Bianca Griffiths Care Home 18 Category(ies) of Learning disability (18), Physical disability (3) registration, with number of places Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 18 residents with learning disabilities, three (3) of whom have additional physical disability 30 November 2005 Date of last inspection Brief Description of the Service: Sistine Manor is a large and spacious detached house, which offers residential care to adults with learning disabilities. The home is located on the edge of Stoke Poges village and within reach of the amenities of the village and Slough town centre. It is also conveniently situated for Wexham Park Hospital. The home is set in large enclosed grounds and there is sufficient on site parking to the front and side of the home. The home is registered for 18 service users between the ages of 18 and 65 and at the time of this inspection there were 14 service users living at the home. 16 of the 18 places are in the main home. Two places are in a separate building, the ‘Coach House’, and are considered suitable for residents who have more independent living skills. The home is run by REACH (Rehabilitation Education And Community Homes Limited) which has its head office in Gerrards Cross. Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector, over the course of a day, in March 2006. The purpose of the inspection was to assess the home’s performance in relation to the remaining key standards, to check progress on the requirements and recommendations of the announced inspection carried out in November 2005, and to consider any other matters of relevance to regulation. The methodology included discussion with the registered manager and staff, interaction with residents, examination of documents, and a walk around the home. Service user support plans are comprehensive in content. The standard of assessment and liaison with NHS CLDT and with social services is good. Weaknesses are apparent in the formulation and implementation of the support plan and these need to be addressed by the registered manager. Service users appeared well cared for and staff showed a positive regard for their welfare. There is a diverse range of needs among the residents of this home, many of whom have quite complex needs, and good practice in support planning is essential in ensuring that those needs are met. The inspection was an opportunity to briefly consider staffing at weekends and the potential effects of the absence of a cook. This has been referred to in inspection reports over the last two years. The review of records covering five weekends finds that there was not a consistent reduction in resident numbers over this period and that the question of an adjustment to staffing numbers to compensate for the absence of a cook remains open. It was pleasing to see that improvements to the environment are continuing – on this occasion by the refurbishment of a bedroom on the ground floor (including the fitting of en-suite facilities) and the purchase of a new freezer. However, it appeared that earlier work on the first floor had not been properly completed and had left loose floorboards and uncarpeted areas. Both posed a hazard to residents. REACH responded promptly to the inspection and to the issues highlighted in feedback to the registered manager at the end of the inspection. The operations manager summarised its response in correspondence received in advance of this report being issued. Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards in this section were not fully assessed on this unannounced inspection. They were fully assessed at the announced inspection carried out in November 2005. EVIDENCE: Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10 Residents needs are carefully assessed and the home liaises with NHS and social services agencies as required. The overall standard of care planning is variable however, in some cases with some sections of care plans only being partially completed or not completed at all. This may lead to residents assessed needs not being fully met. EVIDENCE: A support plan (care plan) is in place for each resident. Four support plans were examined. Each support plan is a fairly substantial document containing a range of information on the resident – including information from other agencies (mainly healthcare agencies and social services). This ensures that staff have all the information they need to develop a care plan to meet residents assessed needs. On this inspection however, the overall standard of practice was found to be uneven. None of the four plans examined had a photograph of the resident. Each of the four plans had significant sections which had not been completed. At the same time however, some plans had excellent assessment information, good protocols for the administration of medication, evidence of good Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 10 communication with health and social services agencies, and good guidelines for staff on the resident’s involvement in daily activities. Assessments were generally of a good standard. The home seems to liaise well with other agencies. Correspondence from health and social services (particularly the former) supplemented the home’s own assessments. In one case it appeared that despite the homes efforts the local social services office (not in Buckinghamshire) was unable to provide a representative to attend a review meeting. Three sections, the ‘personal profile’, communications passports, and guidelines for daily routines, were well written in two of the four plans examined. These were good examples of the potential of the system. However, in the other two plans one or more of the forms had either been left blank or had only been partly completed. Support plans included risk assessments. It was difficult to assess the extent to which some support plans had been put into practice where the entry referred to a wish on the part of a resident to pursue an activity and no further references to this are recorded. One support plan simply listed a cream to be applied, what the resident preferred for breakfast and the routine on going to bed at night. This falls well short of the standards to be expected in such a care service. Some files included good progress reports from the art therapist. Support plans include a form listing ‘current medication’. In one case this included medication from August 2003. It ‘is not clear what this form adds to the information already on the ‘MARS (medicines administration records) sheets which must be retained as part of residents care records. Some sections of support plans are in visual, large print form and written in the first person. It was noted that some plans had references to Makaton (a communications approach which includes signs and symbols) and TEACHH (an approach to working with younger people with autism) but there was no evidence that these approaches had been explored further with the resident or the CLDT. Entries in residents’ daily diaries which, although a separate document, are part of the support plan, varied. Some were very informative in giving an account of the resident during the course of a shift, others merely recorded the care provided. Overall, the structure of support plans, the standard of assessments and the home’s liaison with other agencies is good. Standards are much more variable however in the consistent completion of all sections, in the formulation of a clear support plan for every resident, and in evidencing its implementation in practice (including its presentation in a form which is understandable to each resident). Staff support residents in making decisions within constraints which are necessary for the safety and well-being of the resident. These constraints are Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 11 set out in the risk assessments in care plans. Residents have access to ‘People’s Voices’ advocacy service. Well established arrangements are in place within REACH for the management of residents monies including the secure storage of small amounts of cash for individuals. Residents participate in house meetings and are consulted with regard to outings and holidays. Staff were observed to provide encouraging feedback to residents. Risk assessment processes are well established and numerous risk assessments covering a wide range of daily activities were on file. Risk related to harm to self or others is managed in conjunction with the Community Learning Disability Team. The home is subject to REACH policy on confidentiality. Arrangements for the storage of confidential information are satisfactory. However, staff may need to review practice in relation to information displayed on the office computer screen to ensure that confidential information retained on this medium is secure. Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards in this section were not fully assessed on this unannounced inspection. They were fully assessed at the announced inspection carried out in November 2005. EVIDENCE: Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards in this section were not fully assessed on this unannounced inspection. They were fully assessed at the announced inspection carried out in November 2005. EVIDENCE: Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards in this section were not fully assessed on this unannounced inspection. They were fully assessed at the announced inspection carried out in November 2005. EVIDENCE: Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards in this section were not fully assessed on this unannounced inspection. They were fully assessed at the announced inspection carried out in November 2005. EVIDENCE: A bedroom on the ground floor had recently been refurbished and now included en-suite accommodation. A new freezer had been purchased. Floorboards on the first floor appeared to be loose and posed a hazard to residents. Some of the carpet had been cut away in this area and had not been replaced. This too posed a hazard to residents. Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 16 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): Standards in this section were not fully assessed on this unannounced inspection. They were fully assessed at the announced inspection carried out in November 2005. The notes in this section refer to matters which were discussed with the registered manager during the course of the inspection. EVIDENCE: The subject of staff numbers at weekends had been mentioned in earlier inspection reports. This is because there is not a cook on duty at the weekend and care staff have to prepare meals. It was recommended that REACH employ a part-time cook at weekends. REACH argued that because a number of residents go home at weekends the staff/resident ratio is not significantly affected. CSCI agreed with REACH not to press for a weekend cook providing residents were not disadvantaged by a reduction in care staff time. It goes without saying that all staff involved in the preparation of food should have up to date training in food hygiene. Staff and resident numbers over five recent weekends were examined. This examination did not include an assessment of activity but throughout this time it is noted that one resident required one to one care. Over the five weekends the number of residents registered was 14. The home aims to have five staff on duty in the morning and five in the afternoon. One member of staff is responsible for providing one to one care on each shift. That Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 17 essentially leaves four staff for the remaining residents. Of the ten shifts reviewed over this period, six recorded five staff on duty, and four recorded four staff (both include the staff member allocated to one to one care). On the weekends reviewed the number of residents on leave were three, one, three, one and two respectively. Therefore, the number of residents in the home on those weekends were 11, 13, 12, 13 and 12 respectively. On these figures therefore, resident numbers could not be said to be significantly reduced – particularly when staff numbers were also reduced due to unplanned absence (due to illness for example). The amount of care staff time involved in the preparation, serving and clearing up of meals is time which is not available to residents at weekends. Given the high level of need of many of the residents in this home this matter should continue to be monitored by REACH managers and will be subject to further examination at future inspections. Three new staff had started work in the home: a laundry worker, a care worker and a relief care worker. None of the files were available for examination in the home, they were still held at REACH’s head office in Gerrards Cross. The induction checklist of a new care worker was examined. This was comprehensive but was not equivalent to the TOPSS (now ‘Skills for Care’) induction programme. It covered a wide range of activities but the copy seen did not include target timescales for completion. The registered manager had acquired the Registered Managers award NVQ4. Four staff had recently acquired NVQ 2 and three were expected to start NVQ 3 in the near future. The registered manager reported that external consultants had carried out an analysis of staff training needs but the results were not yet available. Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards in this section were not fully assessed on this unannounced inspection. They were fully assessed at the announced inspection carried out in November 2005. EVIDENCE: Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 19 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 X 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X X X X X X Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 20 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 YA16 Regulation 13 (4) (c) Requirement The registered manager is required to ensure that all staff involved in food preparation have up to date training in food hygiene The registered manager is required to review the home’s complaints procedure to ensure that it is appropriate to the needs of service users The registered manager is required to provide appropriate staffing at weekends when care staff are required to prepare and cook meals for service users The registered manager is required to ensure that staff files contain the information required under Schedule 2 (as amended with the introduction of POVA in July 2005) The registered manager is required to ensure that records relating to the recruitment of staff, which provide evidence of compliance with the Regulations are available in the home from the first day of employment. Timescale for action 28/02/06 2 YA22 22 28/02/06 3 YA18 18(1)(a) 28/02/06 4 YA19 19 15/02/06 5 YA34 19 15/03/06 Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 21 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 Good Practice Recommendations It is recommended that if the home wishes to retain the option of accepting emergency admissions, the registered manager draw up a policy and procedure to manage the process taking into account the increased risk factors in such circumstances. YA35 It is recommended that the registered manager review staff training needs and draw up a training programme for 2006/07. This should include training on infection control and autism and related conditions. YA14YA13YA12YA11 It is recommended that the registered manager conduct a review of the programme of activities and that this include taking account of the views of service users, staff, families, care managers, and of current good practice. YA33 It is recommended that the registered manager maintain clear records of staff numbers and resident occupancy to facilitate analysis by REACH and CSCI of the potential effects of the absence of a cook at weekends. Refer to Standard YA4 2 3 4 Sistine Manor DS0000023021.V287696.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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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