CARE HOME ADULTS 18-65
REACH Sistine Manor Stoke Green Stoke Poges Bucks SL2 4HN Lead Inspector
Nancy Gates Unannounced Inspection 26th July 2007 01:00 REACH Sistine Manor DS0000023021.V339580.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 REACH Sistine Manor DS0000023021.V339580.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. REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service REACH Sistine Manor Address Stoke Green Stoke Poges Bucks SL2 4HN 01753 531869 01753 511873 N/A www.Reach-disabilitycare.co.uk REACH Limited 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) vacant Care Home 18 Category(ies) of Learning disability (18), Physical disability (3) registration, with number of places REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 18 residents with learning disabilities, three (3) of whom have additional physical disability 15th September 2006 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 service users 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. The current range of fees is £706 to £1,414 per week. REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection of the service was a surprise visit and was a ‘key inspection’. The inspector arrived at the service at 1.00 p.m. The total number of hours spent at the home was 10 hours. The time spent at the home allowed for a thorough look at how well the service is doing. The inspection took into account detailed information provided by the service manager inclusive of information that CSCI has received about the service since the last inspection. The inspector asked for the views of the people who use the service. Fifteen household members were in the home at the time of inspection. The inspector also asked the views of others who support the needs of the people who use the service via a questionnaire that the CSCI sent out. All information received by the Commission for Social Care Inspection received, since the last inspection, about this service was also taken into account when producing the key inspection report. Staff and residents were very welcoming. The inspector looked around the home including the bedrooms of the residents at their invitation. A number of records were viewed including resident’s care plans/person centred plans, staff recruitment records, staffing rotas and maintenance records. The inspector looked at how well the service was meeting the standards set by the government. The report includes judgements about the standard of the service. What the service does well:
REACH has good systems for assessing the needs of people who may want to live at Sistine Manor. Referrals are assessed and considered by a director and operations/care services manager. Admission of a new person is carefully considered alongside the needs of the people who live at the home. Risk assessments are good and covered a wide range of day-to-day activities. Care/support plans are reviewed regularly. The reviews for two people were written in a ‘new’ format and included a number of photographs of the individual involved in things that are important in their lives. This is welcomed and demonstrates that the service has recognised the importance of ownership and participation in people planning their lives. Staff support service users in making day to day decisions and will assist individuals who wished to contact the ‘People’s Voices’ advocacy service in Buckinghamshire. REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 6 Needs arsing from equality and diversity are well met. From the evidence seen, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. A varied programme of activities is offered aimed at supporting service users in developing and maintaining social and independent living skills. However, the availability of educational and training events provided by colleges and other organisations remains uncertain. Staff support service users participation in a range of activities; art therapy, music therapy, aromatherapy and massage, gardening, trampoline, and horse riding. Activities being based on personal interests and offered as something people may enjoy. The home has TV, DVDs, videos, a music centre, garden games, board games, books and magazines for use as desired. One member of staff made considerable effort to engage a number of people in different activities throughout the day, clearly recognising likes and dislikes but ensuring people were included when they wanted to be. Staff support a number of service users to remain in contact with their families. Meals are varied and appear to meet the nutritional needs of service users. Service users are involved in menu planning using picture menus. Staff adopt a flexible approach when providing care. Support and encouragement is provided when needed. Access to additional support from health care professionals is provided and meets health needs. Medication is stored securely; administration is accurate, ensuring safety. All elements of risk when dispensing medication from a portable box should be minimised to ensure safety. Effective complaints procedures are in place in an attempt to listen to the views of the people who live at the home and their representatives. Appropriate Safeguarding Adults and whistle blowing procedures are in place, staff are aware of adult protection/safeguarding and were able to describe how to respond appropriately to reports of abuse. A clean, safe and well maintained environment has been created, providing people with a comfortable place to live. The home is a large building with a good-sized garden, which provides space for service users. The home is conveniently located for local services and is a relatively short distance by car for the amenities of Slough town centre. This provides opportunities for service users to access a range of facilities in the local community. A sensory room and activities room is avilable foe use by all residents at any time.
REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 7 Staffing levels are sufficient to meet the needs of current service users. Staff recruitment procedures are satisfactory. The staff training programme provides staff with knowledge and skills required to provide care to service users, however staff do not always use those skills when supporting service users. The home benefits from consistent management arrangements, although a number of issues need to be addressed to ensure service users needs are met appropriately. An application for registration must be submitted to the CSCI. There is regular monitoring by the provider, ensuring that the service operates effectively. Due regard continues to be shown toward health and safety, to reduce the risk of accidental injury to residents, staff and visitors. What has improved since the last inspection? What they could do better:
The overall standard of care planning is variable, and for some individuals sections of care plans have not been completed. The structure of the plans remains complex and may not be readily understood by many of the residents. This does not ensure that individuals assessed needs are being fully met. Progress on PCPs (Person Centred Plans) since the last inspection was not evident. The current format is complex and bulky and does not facilitate the engagement of all residents in the process. Changes to the format have been acknowledged; reviewed and new documentation will be available in the near future. It is acknowledged that changes to care/support plans/PCP’s are planned, however issues regarding the quality of care and support plans have been raised at three inspection visits and changes must be made to ensure individuals assessed needs are recognised and recorded in a way that encourages participation as far as possible. Following the inspection the Operations Manager for the home has confirmed that PCPs have been updated using the new format adopted at REACH. REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 8 The service continues to provide a varied programme of activities aimed at supporting service users in developing and maintaining social and independent living skills. However, the availability of educational and training events provided by colleges and other organisations remains uncertain. The proprietor should continue to undertake a thorough review of activities with stakeholders to ensure that the home is exploring and utilising all avenues of community support in assisting service users develop independent living skills. Staff do not always address people with respect. Staff were overheard when in the lounge to say to a female service user “Naughty girl” and to a male service user “very good man”. Staff must be respectful and cautious when addressing people to avoid being patronising and disrespectful. Meals are varied and appear to meet the nutritional needs of service users, however mealtimes are not always relaxed and unrushed. Behavioural support needs at mealtimes are not always supported appropriately. Personal care is provided in service users bedrooms or bathrooms. However, personal care needs for a female resident were discussed by two female members of staff in the hallway adjacent to the lounge. This must be addressed, as this does not maintain respect and confidentiality. There were a couple of occasions where staff were heard to speaking to each other in the language of their country of origin. REACH has a clear policy that staff must use English at all times in the company of service users and within the home. The manager confirmed that this would be addressed with all staff. Training in non-violent intervention is available to all staff as part of training on ‘Positive Approaches to Challenging Behaviour’, however incidents noted within the ‘Lifestyle’ section of this report highlight that staff are not responding appropriately to ‘challenging’ situations. This must be addressed. Whilst records demonstrate that staff have been provided with numerous training opportunities whilst working for REACH issues identified within the inspection have highlighted a number of concerns. Issues presented within the Individual needs and Choices, Lifestyle and Personal and Healthcare Support sections of this report highlight a lack of understanding in how to support the needs of people with learning disabilities who may have additional behavioural support needs. The inspector acknowledges that the inspection process can mean that staff may become anxious and present a different approach during an inspection visit, however staff must ensure they provide a consistent approach which is within the remit of guidance and training at all times. A manager was appointed to the home in December 2006. The manager was initially employed at the home as a support worker in 2003, promoted to team Leader in 2005 and became manager eight months ago. The operations manager and service development manager continue to provide managerial support as and when required. REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 9 An application for registration has not been submitted to the CSCI, leaving the home without a registered manager for 10 months. The manager stated that an application for registration would be submitted to the CSCI in the near future. An application for registration must be submitted to the CSCI to ensure that the day-today and ongoing development of the service is managed effectively and in the service remains in line with legislation. The Operations Manager has confirmed that an application for registration has been submitted to the CSCI. 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. REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 10 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 REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The needs of potential residents are assessed by experienced staff prior to admission. This ensures that the service can meet assessed needs and minimises the risk of admitting a person whose needs cannot be meet. The process is conducted at a pace, which suits the potential resident, and takes account of the need for current residents and staff to get to know the new person. EVIDENCE: Two new admissions have taken place since the last inspection. Sixteen of the eighteen places in the home are occupied. REACH has good systems for assessing the needs of potential residents. Referrals are assessed and considered by a director and operations/care services manager. Admission of a new resident is carefully considered alongside the needs of the people who live at the home. The process continues to include liaison with the referring care manager, the prospective resident, his or her family members, and others involved with the
REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 12 person. Consideration of relevant information is made following the completion of an assessment form. The homes own assessments are supplemented by information provided by NHS and social services professionals. Following assessment and after considering whether the service is able to meet assessed needs the prospective resident is invited to visit the home. When admission is agreed a three-month introductory placement is arranged. A review is held at the end of the period to ensure the individual and the other members of the house feel happy and comfortable with the admission. The current range of fees is £706 to £1,414 per week. REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The overall standard of care planning is variable, and for some individuals sections of care plans have not been completed. The structure of the plans remains complex and may not be readily understood by many of the residents. This does not ensure that individuals assessed needs are being fully met. Reviews are conducted on a regular basis allowing for the support provided to be consistent, safe and relating to residents changing needs and wishes. EVIDENCE: Six care/support plans were examined. The uneven standards found at the last two inspections remain. All six care/support plans had sections, which had not been completed, were sparse in detail, or contained information that was not relevant to the section heading. In addition, for the majority of staff members English is not their first
REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 14 language and at times information was confusing and in one plan could be considered offensive. Important sections of the some plans were not completed, for example, ‘ Care Plan – pen picture’, ‘The choices I make’, ‘ The things I used to enjoy but don’t do anymore are:’, ‘The things I would like to better or learn to do are:’, ‘New opportunities and things I would like to try are:’, ‘The progress I have made towards my goal’, ‘Support Requirements’, ‘ Health issues’ and ‘Monthly Summary Sheets’. For one individual a support plan included offensive language within the information regarding ‘The Choices I would like to make for myself’. Following discussion with the manager and due to the individuals’ keyworker first language not being English, the word included in the plan was stated to be an incorrect spelling. The manager must ensure the accuracy of support plans to ensure that offensive words are not used within information relating to service users needs. Behavioural support guidelines are also included within care/support plans, however for two individuals were not completed or were not being used by staff to support an individual. A review for one of the individuals conducted in February 2007 highlights the need for guidelines to be available in relation to inappropriate touching and kissing; guidelines were not available. For the other individual guidelines for support during mealtimes, written in April 2005 (reviewed on a 6 monthly basis) clearly describe how staff should support the person but this was not evident during the observation of two mealtimes. Progress on PCPs (Person Centred Plans) since the last inspection was not evident. The current format is complex and bulky and does not facilitate the engagement of all residents in the process. Changes to the format have been acknowledged; reviewed and new documentation will be available in the near future. The manager stated that individuals would be supported and encouraged to engage in the process, however a number of people who live at Sistine Manor may not be able to fully engage in the process due to communication and support needs. Risk assessments remain generally good and covered a wide range of day-today activities. Review intervals varied but all six support plans examined showed evidence of having been reviewed in the last six months. The reviews for two individuals were written in the ‘new’ format and included a number of photographs of the individual involved in things that are important in their lives. This is welcomed and demonstrates that the service has recognised the importance of ownership and participation in people planning their lives. It is acknowledged that changes to care/support plans/PCP’s are planned, however issues regarding the quality of care and support plans have been raised at three inspection visits and changes must be made to ensure
REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 15 individuals assessed needs are recognised and recorded in a way that encourages participation as far as possible. Staff continue to support service users in making day to day decisions and will assist individuals who wished to contact the ‘People’s Voices’ advocacy service in Buckinghamshire. People who use the service working alongside staff in clearing tables after meals, shopping in Slough, picking apples in the garden, taking clothes to the laundry (across a courtyard), vacuuming the home’s car, and participating in the monthly house meetings (of which notes are kept). REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 16 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, 16 & 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The service continues to provide a varied programme of activities aimed at supporting service users in developing and maintaining social and independent living skills. However, the availability of educational and training events provided by colleges and other organisations remains uncertain. Staff do not always address people with respect. Meals are varied and appear to meet the nutritional needs of service users, however mealtimes are not always relaxed and unrushed. Behavioural support needs at mealtimes are not always supported appropriately. EVIDENCE: Staff continue to support service users participation in a range of activities; art therapy, music therapy, aromatherapy and massage, gardening, trampoline,
REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 17 and horse riding. Activities being based on personal interests and offered as something people may enjoy. The situation with regard to service user’s attendance at college remains unclear. Suitable courses and funding remain an issue. Whilst this remains outside of the control of the home it did leave a deficit in the range of activities available to service users. A number of service users attended social clubs on Tuesdays (British Legion), Wednesday (‘The Wednesday Club’) and Thursday (‘Mencap’). Informal outings with staff continue to include visits to pubs or restaurants, walks in the local park, shopping in Slough or Windsor, going to the cinema, and ten pin bowling. Positive comments were received regarding external activities, “Staff are very committed to X and the home organises excellent external activities.” The home has TV, DVDs, videos, a music centre, garden games, board games, books and magazines for use as desired. One member of staff made considerable effort to engage a number of people in different activities throughout the day, clearly recognising likes and dislikes but ensuring people were included when they wanted to be. Staff continue to support a number of service users to remain in contact with their families. Daily routines remain flexible where service users are not committed to appointments in the community. Staff interactions with service users were observed to be generally supportive, however incidents within the lounge and dining room highlighted that staff responded inappropriately to service users at times. Staff were overheard when in the lounge to say to a female service user “Naughty girl” and to a male service user “very good man”. Staff must be respectful and cautious when addressing people to avoid being patronising and disrespectful. The inspector was invited to join service users for dinner. The meal was presented as roast beef, with roast potatoes and vegetables, followed by fruit jelly and/or a piece of fresh fruit. Whilst participating and observing the mealtime, a number of issues caused concern. The behavioural support needs of one service users can influence the pace of mealtimes, the person is known to take food from others during and after they have finished their own meal. Behavioural support guidelines are available but these were not observed to be followed by staff during the meal. The manager stated that the guidelines are often difficult to follow, but the six monthly reviews of the guidelines with no changes recorded since they were written in 2005 suggests that they are current and should be followed. This must be reviewed.
REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 18 The pace of the meal was rushed and anxious, as staff were conscious that the individual might take food from others. People were invited to eat at approximately 5p.m., the majority of people had finished eating both courses and were sat in the lounge by 5.45 p.m. Staff were often heard to say to people, “Have you finished yet…come on X…can I have your plate now.” During the meal food was taken by the individual, staff responded by saying “No X” in a loud voice, grabbing the persons wrists in an attempt to stop the person eating the piece of food, and holding onto the persons wrists to move them away from the dining tables. This did not follow support guidelines and does not follow the non-violent/ ‘Positive Approaches to Challenging Behaviour’ adopted by REACH. The actions of staff at this time did not show an understanding of the individual diagnosed behavioural support needs and raised the question as to whether staff have the appropriate skills to support the individual. The inspector was invited to indirectly observe another mealtime and it is acknowledged that it was a little more relaxed and no incidents were noted. Service users continue to participate in menu planning using picture menus. Meals are prepared by a cook on weekdays and by care staff at weekends. It was stated that some service users participate in preparing meals at weekends. Breakfast consists of fruit juice, cereals, toast and tea or coffee. Lunch is a snack meal. The evening meal consists of two courses and is the main meal of the day. Drinks are available at all times. REACH Sistine Manor DS0000023021.V339580.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. 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. Arrangements for the personal support and healthcare of service users are generally satisfactory, however respect and confidentiality must be maintained at all times. Access to additional support from health care professionals is consistent and meets health needs. Medication is stored securely; administration is accurate, ensuring safety. All elements of risk when dispensing medication from a portable box should be minimised to ensure safety. EVIDENCE: Staff continue to adopt a flexible approach when providing care. Support and encouragement is provided as required. Personal care is provided in service users bedrooms or bathrooms. However, personal care needs for a female resident were discussed by two female members of staff in the hallway
REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 20 adjacent to the lounge. This must be addressed, as this does not maintain respect and confidentiality. Service users continue to choose their own clothes and hairstyles. The multiethnic mix of staff and service users include individuals from the United Kingdom, Czech Republic, Colombia, Italy, Kenya, and Ukraine among others. There were a couple of occasions where staff were heard to speaking to each other in the language of their country of origin. REACH has a clear policy that staff must use English at all times in the company of service users and within the home. The manager confirmed that this would be addressed with all staff. Comments received from service users representatives highlight that language differences can be a barrier to communication and understanding, “The only criticism and it is not a major problem, is that some of the care staff have English as a second language and can be difficult to understand on occasion and occasionally have difficulty explaining things to me”, “I find it difficult to understand what some staff say to me if they are explaining things about X”. All service users remain registered with a general practitioner. Specialist learning disability and mental health services continue to be accessed through the Community Learning Disability Team (CLDT). Psychology, Psychiatry and community learning disability nurses (CNLD) are accessed through the GP or CLDT. Dentists and opticians are accessed through referral although routine dental examinations are available six monthly. A podiatrist visits the home very six weeks (additional charge is made). Speech therapy remains accessible though the CLDT. Massage, Art and Music therapists continue to visit regularly. Medicines are stored in a locked portable box, within a small cupboard in the entrance hall. Additional stock is stored in a locked cabinet within a medication room on the first floor of the home. Staff currently take the portable box out of the cupboard and into the kitchen to dispense medication to service users wherever there are in the home. The portable box cannot currently be made secure once taken out of the cupboard, even though the kitchen is not accessible to service users at this time; this presents an element of risk and should appropriately assessed to ensure safety. A local pharmacist supplies the home with medication with the majority of medication stored within blister pack dispensing systems. Medication administration records are supplied by the pharmacist to support accurate administration and recording. Recording is accurate, no omissions were noted. Medicines returned to the pharmacy are recorded appropriately. The organisation provides training for staff in the administration of medicines and there are written guidelines in place on the use of all as prescribed medication. A protocol remains in place for the administration of PRN (to be taken as required) medicines for each resident.
REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 21 REACH Sistine Manor DS0000023021.V339580.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Effective complaints procedures are in place in an attempt to listen to the views of the people who live at the home and their representatives. Appropriate Safeguarding Adults and whistle blowing procedures are in place, Staff do not always respond to challenging situations appropriately. EVIDENCE: REACH policy and procedure guides the management of complaints. The home has received five complaints since the last inspection, response to the complainants was within 28 days; the complaints were investigated appropriately. No formal complaints have been received at the CSCI since the last inspection. A complaints procedure is available including the details of the CSCI. The procedure detailing that the complainant can refer to the CSCI at any stage. The complaints procedure has also been made available in an alternative format. REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 23 The inspector recognises that the communication needs of the people supported at Sistine Manor vary and therefore the formats currently available may not meet everyone’s needs. The service has good arrangements for Safe Guarding the people at Sistine Manor. A clear policy remains in place alongside training for staff. The manager stated that a copy of the current Buckinghamshire joint agency guidelines on the protection of vulnerable adults is available at the home. Protection of Vulnerable Adults/Safeguarding adults remains within the organisations induction programme. Staff are aware of adult protection/safeguarding and were able to describe how to respond appropriately to reports of abuse. Systems for managing service user’s monies appear generally satisfactory, although minor discrepancies were noted when checked during the inspection. The manager should ensure that staff accurately record money available to service users. Training in non-violent intervention is available to all staff as part of training on ‘Positive Approaches to Challenging Behaviour’, however incidents noted within the ‘Lifestyle’ section of this report highlight that staff are not responding appropriately to ‘challenging’ situations. This must be addressed. REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 24 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 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A clean, safe and well maintained environment has been created, providing people with a comfortable place to live. The home is a large building with a good-sized garden, which provides space for service users. The home is conveniently located for local services and is a relatively short distance by car for the amenities of Slough town centre. This provides opportunities for service users to access a range of facilities in the local community. EVIDENCE: The home is a large detached house in the village of Stoke Poges. Slough town centre is a relatively short distance by car, bus or taxi. The home has a
REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 25 large and secure garden to the rear and a large pick up/drop off and car parking area to the front. Staff controls entry to the home. The main house accommodates 16 service users and an adjacent coach house could accommodate 2 service users in a first floor flat. The premises provide spacious accommodation. A programme of refurbishment and redecoration has been under way for the last couple of years and evidence of this continuing was again observed on this inspection. The ground floor accommodation includes a large entrance hall, kitchen, two dining rooms, a large lounge; staff work station, a sensory room and a bedroom, which includes en-suite facilities (shower and WC). Across a small courtyard are a games room, laundry, store area (with freezers) and entrance to a self-contained two bedroom flat. The flat within the coach house was not in use at the time of this inspection. The accommodation comprises a living/dining room, two single bedrooms, kitchen, bathroom and WC. The garden is a pleasant area, large, with areas of lawn, mature shrubs and trees and which is reasonably secure. It continues to provide plenty of space for service users. Stairs lead to the first floor. This includes the manager’s office and the medicines storeroom. Bedrooms vary in size. Five were inspected with the service users’ permission. The rooms were of good size, comfortably furnished, clean and tidy and decorated in line with the wishes of the service user. There are nine WCs and five bathrooms around the home. The lounge is large, remains bright and quite well furnished. It has a TV, music centre, radio, games and magazines. There are two dining rooms – one large and one small – both suitably furnished. The laundry is situated in a separate building across a courtyard. A cleaner who is employed on a part time basis is helping to do the laundry until a laundry assistant is employed. All areas of the home appeared clean and there were generally no unpleasant odours. REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 26 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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staffing levels are sufficient to meet the needs of current service users. Staff recruitment procedures are satisfactory. The staff training programme provides staff with knowledge and skills required to provide care to service users, however staff do not always use those skills when supporting service users. EVIDENCE: At the time of the inspection, the home had 14 full time care staff and 3 domestic staff and 3 relief staff. The home currently has vacancies for 4 care staff, a team leader and a laundry assistant. Four people have been recruited to the care staff vacancies and are waiting for reference checks and Criminal Records Bureaux clearance. The manager stated that four care staff had achieved NVQ2 but was unable to confirm whether any staff had achieved NVQ level 3. The staffing also includes staff who are qualified as nurses in their country of origin.
REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 27 Staff recruitment continues to be co-ordinated by the human resource department of REACH in Gerrards Cross. Applicants are required to complete an application form, supply two references, have an enhanced CRB certificate or ‘POVA first’ and supply medical information prior to taking up post. Overseas staff supply a CV via a recruitment agency under contract to REACH. Senior managers interview all staff. The inspector examined five staff files and was satisfied that the organisation operates a thorough recruitment procedure to protect residents and staff. The manager confirmed that POVA first checks before staff start work at the home. This is completed alongside a CRB check. Staff training and development continues to be organised from the human resources department. REACH continues to provide a range of training events over the course of the year. Courses include: ‘Non-Violent Crisis Intervention’, ‘Infection Control’, ‘Autism’, ‘Managing Medication’, ‘Moving & Handling’, ‘Health & Safety in Care Homes’, ‘Cultural Awareness’, ‘Risk Assessment’, ‘Sexuality’, ‘Food Hygiene’ and ‘Fire Prevention’, ‘Protection of Vulnerable Adults’. Whilst records demonstrate that staff have been provided with numerous training opportunities whilst working for REACH issues identified within the inspection have highlighted a number of concerns. Issues presented within the Individual needs and Choices, Lifestyle and Personal and Healthcare Support sections of this report highlight a lack of understanding in how to support the needs of people with learning disabilities who may have additional behavioural support needs. The inspector acknowledges that the inspection process can mean that staff may become anxious and present a different approach during an inspection visit, however staff must ensure they provide a consistent approach which is within the remit of guidance and training at all times. Staff are informed of the aims and values of the home through induction, supervision, training and development, and staff meetings. Staff are supplied with a copy of the GSCC codes of practice. One to one supervision of staff is established and staff files examined during the course of the inspection showed that supervision sessions are generally held monthly. All staff continue to have an annual appraisal, which is a structured process and includes consideration of training needs and objectives for the following year. Staff spoken with were positive in their views regarding the support and training offered by REACH. REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 28 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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home benefits from consistent management arrangements, although a number of issues need to be addressed to ensure service users needs are met appropriately. An application for registration must be submitted to the CSCI. There is regular monitoring by the provider, ensuring that the service operates effectively. Due regard continues to be shown toward health and safety, to reduce the risk of accidental injury to residents, staff and visitors. REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 29 EVIDENCE: A manager was appointed to the home in December 2006. The manager was initially employed at the home as a support worker in 2003, promoted to team Leader in 2005 and became manager eight months ago. The operations manager and service development manager continue to provide managerial support as and when required. An application for registration has not been submitted to the CSCI, leaving the home without a registered manager for 10 months. The manager stated that an application for registration would be submitted to the CSCI in the near future. An application for registration must be submitted to the CSCI to ensure that the day-today and ongoing development of the service is managed effectively and in the service remains in line with legislation. The manager stated that she is a physiotherapist, but has no formal management qualifications, “just experience”. The manager is expecting to start the registered Managers Award and NVQ level 4 in September 2007. Formal and informal review of residents’ opinions is sought on a regular basis, house meetings providing a forum for the people who live at Sistine Manor to express opinions. Reports of monthly monitoring visits by the provider are held and provide good evidence of detailed monitoring. Arrangements for safe working practices appear satisfactory. A senior manager is responsible for health and safety across the organisation. A copy of health and safety guidance and policies remains available in the manager’s office. REACH continues to ensure that new staff receive initial training during their induction and probation period in moving & handling, fire safety, first aid, food hygiene and infection control. Risk assessment processes remain well established. The health and safety records relevant to the inspection were viewed. The records are well maintained and up to date. Processes for conducting risk assessments remain at a good standard. REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 30 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 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 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 1 X 3 X X 3 X REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement The provider must review and update care/support plans for all service users to ensure assessed needs are recorded appropriately. The provider must review staff skills to ensure that staff maintain confidentiality and regard service users with respect at all times. The provider must review staff skills, ensure that appropriate guidelines and training are in place in relation to supporting people with challenging needs to ensure the safety and welfare of service users and staff. The provider must ensure that the manager of the home submits an application for registration to the CSCI to ensure that the day-today and ongoing development of the service is managed effectively and in the service remains in line with legislation. Timescale for action 31/10/07 2 YA10 YA18 12:4 (a) 24/08/07 3. YA23 13 (7) 30/09/07 4. YA37 8&9 07/09/07 REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 32 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 YA12 Good Practice Recommendations The proprietor should continue to undertake a thorough review of activities with stakeholders to ensure that the home is exploring and utilising all avenues of community support in assisting service users develop independent living skills. The proprietor should ensure that staff do not speak to each other in the language of their country of origin in accordance with REACH policies. The manager should ensure that staff accurately record money available to service users. 2. 3. YA18 YA23 REACH Sistine Manor DS0000023021.V339580.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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
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