Inspection on 28/09/05 for Safeharbour

This inspection was carried out on 28th September 2005.

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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Safeharbour 09/09/09

Safeharbour 14/08/07

Safeharbour 12/07/06

Safeharbour 10/03/06

Safeharbour 17/03/05

Safeharbour 06/09/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Safe Harbour 52 Corbett Avenue Droitwich Spa Worcestershire WR9 7BH Lead Inspector Jean Littler Announced Inspection 28th September 2005 11:00 Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 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 Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 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. Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Safe Harbour Address 52 Corbett Avenue Droitwich Spa Worcestershire WR9 7BH 01905 796214 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) Dr Anjani Kumar Mr Geoffrey Moultire Copeland Jolene Lisa Riggs Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service is for people with a learning disability but the Home may also accommodate people with an additional mental disorder. 17th March 2005 Date of last inspection Brief Description of the Service: Safe Harbour is situated in a quiet residential area within a short distance of Droitwich Spa town centre and a wide range of amenities. The premises are in keeping with the environment and the local community. Accommodation is provided on two floors. All the service users have their own single bedroom. The home provides a service for six people with learning disabilities who have high support needs, some of whom may also have an additional mental disorder. The age range of the current service users is 34 to 45 years. One of the stated aims of Safe Harbour is to provide a comfortable and secure home for as long as the individual service users need it and to encourage and enable them to develop to their maximum potential. The home also seeks to promote within each individual, the belief that their life and activities are of value and as valid as other peoples. Safe Harbour Care Homes operated as a partnership and has two registered proprietors namely, Dr. A Kumar and Mr. G Copeland. Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine announced inspection was carried out on a weekday between 11am and 5.30pm. The manager completed an inspection questionnaire to provide additional information. The residents’ representatives were provided with questionnaires, four of which were returned with positive feedback. A fifth raised some concerns about past issues and the Commission has written a separate response. The manager arranged for the residents’ questionnaires to be designed in a symbol format and two residents gave positive feedback through this method with staff assistance. The manager assisted with the inspection process and two support workers were interviewed. The inspector met some of residents and was able to see them interacting with the staff on duty. The providers monthly visit reports to the Commission, and other communication with the Home since the last inspection were all considered as part of the assessment process. A recent short notice inspection was carried out as a result of a report about a medication error. A summary of the findings and the requirements and recommendations made as a result of this have been included in this report. A copy of the full findings are available from the Home or the Commission on request. What the service does well: What has improved since the last inspection? A new manager has been appointed very recently and good progress is already being made towards addressing many areas. These include increasing the number of permanent and fully trained staff, developing more effective staff support structures, assisting staff to gain formal training awards, better daily planning for residents to increase their range of activities and improve their quality of life, facilitating better communication systems for residents, and making further improvements to the premises. The home is now in a good position to consolidate the staff team and focus totally on residents’ needs. Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 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 Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 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): EVIDENCE: These standards were not fully assessed, however information about the Home is in place and has been recently reviewed. The manager is developing a Service User’s Guide in a format that is more suited to the needs of the residents. A Terms and Conditions of Residency document is in place. The manager agreed to check that these include the room number for each resident and covers how the resident’s holidays will be funded. There are no current vacancies but the manager is aware of the need to complete a full assessment and demonstrate that all assessed needs can be met before admitting a new resident into the Home. Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 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 Care planning systems are being improved as some information is not accurate and has not been kept under review. The arrangements in place to promote effective communication with residents are being improved to allow them to make more informed decisions about their lives. EVIDENCE: Care plans were sampled and those seen contained a lot of useful information for staff about each resident’s complex needs. Some information has not been updated since 2004 and is no longer accurate. A new care planning system has been put in place for all residents that is more Person Centred and the manager has sessions planned with the staff to introduce this to them. Keyworkers will then take on responsibility for completing these with senior support and with the involvement of the resident and their representatives. On one file there was no evidence that a review had been held since March 2004 despite the resident having very complex needs. The manager agreed to explore when reviews had last been held and arrange these if needed for all residents. Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 Page 10 Good work is taking place to further develop methods of communication including symbol systems and visually displayed information e.g. personal activity plans. The manager is exploring total communication training and has employed a member of staff specifically to develop this area. Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14, 15 Residents are being provided with increasing opportunities to take part in suitable and enjoyable activities in and out of the Home. Good efforts are being made to support links between residents and their families. EVIDENCE: Activity opportunities are being further developed. Each resident has a plan that includes a mixture of planned external activities, in-house sessions and leisure outings. The sensory room is unlocked and available for residents to use to relax. This has been newly decorated and is fitted out with a variety of equipment to suit different preferences and a music system to enhance the atmosphere. Taster sessions have been introduced for enjoyment and to help develop the menus based on residents’ preferences. Routines seemed to be flexible and only a few necessary restrictions are in place. It was positive that a resident was seen coming into the kitchen and helping herself to a drink and snack. Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 Page 12 Planned activities are accessed include horse riding, trampolining, swimming, and the gym. Holidays have been arranged in small groups e.g. three residents are due to go to Butlins and others stayed in a cottage in Wales. Two residents are due to start a college course soon. It is very positive that work opportunities are being developed e.g. one resident is supported to have a paper round and does some agreed housework tasks and receives therapeutic earnings. A new member of staff has been recruited specifically to take the lead on arranging activity plans that meet the residents’ individual needs. Residents are being supported to keep in close contact with their families e.g. visits are encouraged and telephone contact maintained. Families reported in the questionnaires that they are appropriately consulted about care issues. Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 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): 18, 19 Suitable arrangements are in place to meet residents’ personal care needs in a flexible and responsive manner. Residents’ behavioural needs are being appropriately met with the support of external professionals. Health care is being given priority and appropriate specialists are involved. EVIDENCE: Residents privacy is being respected e.g. one resident keeps her room locked when empty and staff do not enter without her permission. The only female resident has one of the bathrooms allocated to her to enable her to leave her belongings out and make the room more feminine. Residents are being supported to attend health appointments and medication regimes were being reviewed. Residents are being encouraged to be active and be aware of their health e.g. on resident goes to a keep fit session each week. A cook works three days a week and a health and varied diet is being promoted. Tests are being carried out as staff identified that one resident is chronically tired. Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 Page 14 A protocol is in place detailing how one resident with severe epilepsy is provided with life saving medical intervention. The protocol has been developed by the professionals involved in his medical care. The manager agreed to ensure it was kept under review and accurately reflected the current medical instructions. Staff are appropriately trained to administer emergency medication in line with this procedure. The staff spoken with reported that these difficult and sometimes distressing situations are managed in a calm, efficient and caring manner. Structures are in place to support staff to meet residents’ complex behavioural needs in a consistent and professional manner. Strategies are included in the care plans, professional support is accessed, regular staff meetings, supervisions and daily shift handovers are held, staffing levels are high and staff support a designated individual for that shift. Staff spoken with reported that the team works well together to identify triggers and redirect a resident quickly to reduce the likelihood of anxiety escalating into aggression. The manager is clear that if other strategies are used effectively physical intervention is not needed. A referral has been made for speech therapy for one resident. The manager was advised to consider asking for an occupational therapy assessment for one resident who has some mobility difficulties. Arrangements for medication management were not fully assessed, however the manager reported that the way medication for emergency epilepsy treatment is organised has been made more robust following a recent incident when some of this medication was mislaid within the Home. Following a recent medication administration error the Home’s procedure had been reviewed, photographs of residents had been added to the administration charts, additional staff training was being arranged and a system of in-house competency checks introduced. Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The manager responded positively to a complaint raised during the inspection. Recording of complaints and access to the complaints procedure should be reviewed. Procedures are in place to help protect residents from abuse. The providers are co-operating fully with an on-going adult protection investigation. The manager responded appropriately to recent protection issues and has learnt from another incident that to protect residents it is essential to operate the service in a transparent manner and keep clear records. EVIDENCE: A complaints procedure is in place. Some relatives indicated in the questionnaires that they are not aware of this. The manager agreed to send copies out to all residents’ representatives. A neighbour made a complaint during the inspection. She reported that staff park their cars inconsiderately and play loud music from their car stereos causing a disturbance. She has heard staff swearing whilst in the garden having their breaks and finds the vocalisation sounds made by some residents and the music played in the house disturbing to her and her family. The manager responded to the complaint in a professional and helpful manner. She agreed to investigate these concerns and report back to the complainant within two weeks. The complainant reported that she had raised similar concerns to the previous manager earlier in the year but these were not dealt with Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 Page 16 satisfactorily. She had been informed that one of the providers would come to talk to her about her families concerns but had not done so. The provider had not informed the new manager about these issues and the manager had not found the information in a complaints record. Suitable policies are in place regarding abuse and staffs’ duty to report concerns to protect residents. Staff training in abuse and protection is being provided to help equip staff to protect residents. A vulnerable adults investigation has been carried out over the previous six months under the local multi-agency procedure. The providers co-operated with this process and safeguarded the residents by suspending the staff involved. The process has not yet been fully concluded and will be reported upon at the next inspection. A recent concern was raised when the manager discovered that a resident’s wallet and cash was missing but several senior staff had continued to sign for over a week that the balance in the resident’s cash record book was correct. This was appropriately reported to the Commission by the manager and was investigated by the police in line with a multi-agency vulnerable adults procedure. When the police dropped the case the manager was asked to carry out an in-house investigation. The findings were inconclusive but financial procedures were strengthened and all staff were spoken with at a staff meeting. The records from the investigation process showed that the manager would benefit from training in disciplinary processes. An allegation that a medication error had been covered up was reported to the Commission anonymously on September 8th 05. A short notice inspection was carried out on September 15th to investigate the allegation by two inspectors, one of whom was a pharmacy inspector. The manager had been aware of the error and reported that she had forgotten to inform the Commission. The provider and the resident’s family had also not been informed. The GP had been contacted but care and medication records did not contain any reference to the events. The complaint was therefore substantiated and requirements and recommendations were made. These have been detailed in the last section of this report. The manager has provided a suitable action plan to address these and confirmed that she is aware that to protect residents the service must operate in a transparent manner. Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 29, 30 The Home is suited to its purpose, with the exception of the small garden. The house is being well maintained and provides residents with an attractive and homely place to live. Adaptations have been made to meet residents’ special needs. Some premises issues have been identified for the manager to follow up, and infection control arrangements need to be improved. EVIDENCE: The Home has large rooms and has been attractively decorated and comfortably furnished. The garden is very small and is inadequate for the young and mobile group of residents. To balance this an allotment is used and recently residents have been getting more involved and have grown vegetables. The Home is being well maintained and some areas have recently been redecorated e.g. the hall and landing. A small quiet area has been set up for staff to work on their administration duties on a computer. There are other improvements planned including new carpets in some areas and the redecoration of the lounge. Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 Page 18 The bedrooms have been personalised although some of the residents prefer their rooms to be kept quite clear. One resident recently requested to change the colour of his bedroom walls and was assisted by staff to do the painting himself. One resident does not want a lamp shade so the bare light bulb should be replaced with a flush light fitting. There are a sufficient number of bathrooms and toilets to meet the residents’ needs. One bathroom would benefit from redecoration and refurbishment. A normal light fitting in a downstairs bathroom needs to be replaced with a covered bathroom fitting to reduce the risk of electrocution. The manager agreed to risk assess the hot water outlets that could pose a risk of scalding to residents and take appropriate action to reduce this hazard. It would help promote the residents’ dignity if closed storage is provided for their personal care supplies. Staff have not been provided with bathroom facilities for when they are sleeping in. Consideration is being given to making one toilet a staff only toilet, but this is not near the sleep-in room. The environment has been adapted to meet residents’ special needs e.g. air conditioning has been fitted in one residents bedroom to help a medical condition, a raised toilet seat has been fitted to assist a resident who has some mobility difficulties. Consideration should be given to a full occupational therapy assessment being carried out for this resident to ensure all suitable aides and adaptations are being provided. One resident’s low windows need to be risk assessed as he often falls and the glass may not be safety glass. The manager was advised to clarify with the Fire Officer about some issues discussed, including one resident’s bedroom door closure that is regularly being damaged. The cellar where the laundry is sited had recently flooded following heavy rain fall. The manager was exploring the possibility of having a pump fitted. New lino flooring had been laid but not under the machines as any movement would cause rips. Flooring in laundry areas should be of a type that can be thoroughly cleaned. The manager was advised to contact the Environmental Health office for advice on flooring and hand washing arrangements in the laundry and throughout the house. Some suitable infection control arrangements were already in place e.g. coloured chopping boards, however a pedal bin was needed in the kitchen, and alternative methods should be found to manage soiled laundry instead of sluicing items by hand. Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 36 Suitable staffing levels are being provided and through recruitment efforts the number of hours covered by agency staff has been significantly reduced. Supervision and support structures are in place and staff felt supported by the manager. EVIDENCE: The sample of rotas seen showed that suitable staffing levels are being maintained. There has been a significant turnover of staff in recent months, however this is viewed by the management team as being mainly positive to the long-term quality of the service. The manager has worked hard to recruit replacement permanent staff and has been successful in reducing the number of hours covered by agency workers. The majority of agency hours are now being used to employ three regular workers who know the residents well. When the new staff start, who are currently being recruited, the team will be in a good position to settle and develop the service. Support staff are provided including a domestic assistant six days a week and a qualified cook who works three days a week. A training plan is held for each worker and an overview matrix is on the office wall. Good efforts are being made to provide appropriate training e.g. new staff have started the LDAF induction and foundation units and are being Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 Page 20 provided with core training. Other staff are also doing the LDAF units and all are starting either an NVQ 2 or 3. Several staff have been completing a unit based course over several months on infection control. As detailed above training in medication administration needs to be further developed now that accredited courses are available. Specialist training is also being provided e.g. epilepsy. It would benefit the residents if the level of training around their learning disabilities were increased e.g. more input on autism, total communication needs, positive approaches to behaviours that are challenging, and physical intervention techniques (in case this is needed). The range of training needed for this specialised service is wise. Many of the staff team are new so training will need to remain a high priority for the manager over the coming year. The recruitment records sampled showed that processes have been made more robust and clear records are being kept. Job descriptions should be held on each workers’ file to evidence that they have been issued with a copy. The requirements of the Protection of Vulnerable Adults Guidance and amended Care Home regulations to explore any employment gaps and establish why a candidate left previous jobs with vulnerable people were discussed. The benefit of introducing an equal opportunities policy when internal vacancies occur was discussed. An acceptable CRB check was held for each person employed and it was agreed that these could now be destroyed in line with the CRB guidance. Appraisal forms are in place and all staff will now receive a six monthly appraisal. Regular supervision is now being provided for staff and a supervision log has been set up to monitor this. The appointment of a deputy would strengthen the staff support systems. The frequencies of supervision sessions should be kept flexible dependant on staffs’ needs e.g. more often if there are competency issues. The benefits of a supervision contract were discussed. The staff spoken with reported that they felt supported and that the manager was approachable and helpful. Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 40, 41, 42 The management arrangements, policies and record keeping systems have been significantly improved. The Home is now in a good position to develop the service and further improve the quality of life for the residents. Some health and safety shortfalls were noted in relation to the premises, staff training and infection control arrangements. EVIDENCE: The new manager has been in post for nearly three months. She has worked in a similar post previously and has applied for registration with the Commission. There are plans to appoint a deputy to support the manager if her registration application is successful. The feedback obtained from staff about the manager indicated that she is approachable and helpful. It is positive that she works regularly with the residents to ensure she is aware of their needs. Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 Page 22 Record keeping systems are currently being reviewed and improved e.g. recruitment records. The manager acknowledges that appropriate records relating to a recent medication error and a resident’s missing money were not kept. She has confirmed that she will ensure accurate records will be maintained by her staff in the future. The manager has appropriately reported incidents to the Commission with one exception, as detailed above. She confirmed that she is now aware of the importance of transparent management and openness with the Commission and other stakeholders. The pre-inspection questionnaire showed that a full set of policies and procedures are now in place and being kept under review. The manager has been pro-active in reviewing these as issues have arisen. Staff are being asked to sign to show they have read the procedures. A member of staff is beginning work to make relevant policies available in a format more suitable for the residents. The pre-inspection questionnaire provided evidence that the majority of suitable maintenance checks are being carried out and equipment is being serviced e.g. fire extinguishers. Although the lift is not used regularly, if it is to be kept in working order the safety and maintenance arrangements need to be clarified with the Environmental Health Officer. The manager should also clarify when the gas, electrical wiring, and central heating systems were last inspected as these dates were not provided. The level of first aid training currently being provided is below the National Minimum Standard. The manager needs to complete a risk assessment and if additional training is identified as needed this should be provided as soon as possible. The majority of staff have attended a recent fire awareness training session. A drill had been held in June and the manager is aware that as well as staff attending annual training they should also take part in a drill at least once a year. Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 2 1 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X 3 X 3 2 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 X 2 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Safe Harbour Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 2 1 X DS0000018672.V255733.R01.S.doc Version 5.0 Page 24 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 YA38 YA41 YA20 YA6 YA19 YA41 Regulation 37 Requirement All incidents effecting service users’ wellbeing must be reported to the Commission without delay. Accurate records of medication administration details must be maintained at all times. Accurate care records must be maintained at all times that include significant health issues and any action taken to address these. The provider’s monthly visits, that report on the conduct of the Home, must monitor any significant incidents, reporting processes and the accuracy of record keeping. Clear records must be kept of any internal investigations and/or disciplinary processes. Timescale for action 16/09/05 2 3 13 17 Schedule 3 and 4 26 16/09/05 30/09/05 4 YA38 YA41 30/09/05 5 YA41 17 Schedule 3 30/09/05 6 YA42 13, 16 Requirements made following the inspection on 28/9/05 The normal light fitting in the 15/10/05 downstairs bathroom must be changed for one suitable for a bathroom. Confirmation that this had been actioned was received on 7/10/05 DS0000018672.V255733.R01.S.doc Version 5.0 Page 25 Safe Harbour 7 YA35 YA42 13 A qualified First Aider must be on 31/10/05 duty at all times unless a risk assessment clearly shows that this level of cover is not needed. The risk assessment must be completed in one month and any additional training identified provided within six months. Confirmation was received on 7/10/05 that all senior staff will attend full first aid training by March 06. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA38 Good Practice Recommendations The providers should review the guidance given to the manager about reporting incidents to service users’ relatives and representatives. The manager confirmed on September 28th that she will report any future events appropriately to residents’ representatives. Arrange for the competence of all staff to administer medication in line with the Home’s policy to be reassessed periodically. Keep a record to evidence this process. The manager confirmed on September 28th that staff will be provided with periodic refresher training courses from the supplying pharmacist, the first of which has been booked. She also plans to quiz staff to ensure they are fully aware of the Home’s medication procedure. Arrange for all staff who administer medication to attend accredited training in the management of medication. The manager confirmed on September 28th that all staff have been enrolled onto an accredited training course. Attach a photograph of each service use to their medication administration chart. This had been actioned by the 28th September. Arrange for the manager to attend training in the management of investigations and staff disciplinary procedures and legal framework. The manager confirmed on October 5th that she has identified a course to attend. 2 YA20 3 YA20 4 5 YA20 YA37 YA43 Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 Page 26 6 YA41 The providers should oversee disciplinary processes and ensure the manager is guided appropriately. Review the residents’ financial management systems to see if they can be made more robust. The manager confirmed during the inspection on 28th September that procedures had been reviewed and improved. Good practice recommendations made following the inspection on 28/9/05. Consult the Fire Officer regarding the premises issues discussed during the inspection. Fit safety glass in one resident’s low-level bedroom window as he is prone to falling heavily. Confirmation was received on October 5th that this had been actioned. Liaise with the Worcestershire Person Centred Planning coordinators and consider introducing the ‘My Life’ planning approach. Confirmation was received on October 5th that this had been actioned and a meeting arranged. Review infection control arrangements. Confirmation was received on October 5th that suitable action had been taken. Ensure all representatives are informed about the Home’s complaints procedure. Confirmation was received on October 5th that copies of the procedure have been sent out to all representatives. Ensure staff are recruited in line with the Vulnerable Adults guidance issued in July 2004. Ensure all staff have a job description and place a copy on their personal files. Introduce an equal opportunities recruitment policy. The manager confirmed on October 5th that these steps have been actioned. Consult the Environmental Health department to clarify the frequency of lift services, suitable floor covering in the laundry and best practice arrangements for infection control. Confirmation was received on October 5th that an EHO inspection had been requested and arranged. Establish when the gas, electrical wiring, and central heating systems were last inspected. Ensure all staff attend core and specialist training relevant to the service in a timely manner. Continue to develop care planning systems and ensure residents have care reviews at least every six months. Risk assess the hazard posed to residents from hot water outlets and take any appropriate action to reduce this risk. The manager confirmed on October 24th that control mechanisms were being fitted to hot taps and the shower. DS0000018672.V255733.R01.S.doc Version 5.0 Page 27 7 8 YA42 YA42 9 YA6 10 11 YA30 YA22 12 YA34 13 YA30 YA42 14 15 16 17 YA42 YA33 YA35 YA6 YA42 Safe Harbour Commission for Social Care Inspection Hereford Office 178 Widemarsh St Hereford Herefordshire HR4 9HN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Safe Harbour DS0000018672.V255733.R01.S.doc Version 5.0 Page 28 - 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. 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