Inspection on 05/06/06 for Shaftesbury Place

This inspection was carried out on 5th June 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shaftesbury Place 15/04/08

Shaftesbury Place 12/07/07

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Shaftesbury Place 52 Marsland Road Cheltenham Glos GL51 0JA Lead Inspector Ms Lynne Bennett Key Unannounced Inspection 5th & 6th June 2006 10:00 Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Shaftesbury Place Address 52 Marsland Road Cheltenham Glos GL51 0JA 01242 227818 01242 228607 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) www.sanctuary-care.co.uk Sanctuary Care Ltd To be appointed Care Home 17 Category(ies) of Learning disability (17), Physical disability (17) registration, with number of places Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To include registration of one flat on the first floor for a named service user (category PD). 16th January 2006 Date of last inspection Brief Description of the Service: Shaftesbury Place is home for 17 people with a physical disability and mild learning disability. The home has just been taken over by Sanctuary Care who will be responsible for the provision of care and the tenancies of people living at the home. Shaftesbury Place is purpose built for people who are wheelchair users and the accommodation has level access throughout. There are four self-contained units each providing single accommodation, bathroom/shower and toilets, as well as a kitchen and dining area. There is a large communal lounge, separate laundry facilities and a private area for the use of a public telephone. A flat on the first floor is also registered to a named resident. The flat has a bed-sitting room, bathroom and kitchen. The home is ideally situated for access to Gloscat and local shops and the town centre is easily accessible by transport. People living at the home can book the home’s mini bus or use local taxis and a voluntary car service. Fee levels range from £450 to £722 per week. Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This inspection took place in June 2006. Visits to the home were completed on 5th and 6th June. A pre-inspection questionnaire was returned prior to the visit as well as four comment cards from people living at the home. Time was spent observing the care of people living at the home and talking to them about their experiences. Interviews were conducted with six members of staff. A range of records were examined during the visits including care plans, financial and medical information, staff records and health and safety records. A walk around the environment was carried out and people being case tracked showed the inspector their rooms. The home has been through a period of turmoil. There has been no registered manager for almost a year and a succession of acting managers. Staff turnover has been high and there has been a dependency on agency staff. Interviews for the post of registered manager take place in June 2006. At the time of the visits a team leader had been promoted to acting manager. She was not present during these visits. Staff and people living at the home have also been through a period of transition during the handover of the management of the home to Sanctuary Care. Despite this morale at the home is good and people are positive about the future development of the home. What the service does well: What has improved since the last inspection? There has been a significant improvement in the quality of care plans and risk assessments. There is regular review and monitoring in place. People living at Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 6 the home are signing their plans. Agency staff say that they have access to these records and discussions with them confirmed their understanding of the needs of the people they support. Key worker systems are in place and people living at the home speak positively about the relationships that are developing. They have access to key worker files in their rooms that they are just beginning to complete. People living at the home said that communication systems have improved with regular house meetings and access to management. A robust system for monitoring health and safety is in place, making sure there is regular servicing and testing of equipment. Morale amongst the staff team has improved benefiting people living at the home. 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. Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service User Guide are being reviewed to ensure that people living at the home have access to the latest information. By providing this information to people wishing to move into the home they will be able to make an informed choice about whether they wish to live there. A comprehensive admissions process is in place that assesses the needs of prospective residents to ensure that the home can meet these needs. EVIDENCE: The Statement of Purpose and Service User Guide are being reviewed in line with changes to the care provider and within the home. When these documents are completed they are to be made available to people living at the home and copies forwarded to the Commission. There have been two new admissions to the home since the last inspection. Both people were spoken to and said that they like living there. They both confirmed that they had an initial one-month’s assessment at the home followed by a three-month review with their placing authority. One person had copies of this review in their room – it is recommended that one of these copies is put on their file in the office so that key workers can refer to their identified needs when drawing up their care plans. (See also Standard 6). Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 9 One person said that their initial assessment at the home had been a difficult time for them because their expectations were different from their experience of the home. They had not realised they would be encouraged to be independent and felt uncomfortable for a while. With the support of staff they said they are now more confident and happier at the home. This is why the Statement of Purpose and Service User Guide are such important documents for prospective residents so that they do not move into the home with unrealistic expectations. Staff confirmed that they visit prospective residents at their present placements to carry out an assessment. A comprehensive assessment had been carried out for one person. This is good practice. There was a note to indicate that another prospective resident was to have a similar assessment. Placing authorities provides care plans and a single assessment of need and information is also provided from previous residences. Staff said that they encourage people to visit the home prior to moving in for their month’s assessment. One person is having another visit this week. All people living at the home have copies of the contract in place with their placing authority and a tenancy agreement and licence agreement. Staff indicated that Sanctuary Care would like all their documentation to be in place by September this year. Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Significant improvements in the care planning process provide staff with information they need to meet the needs of people living at the home. There is no formal assessment process in place that would identify changes to need. People living at the home are consulted and involved in the running of Shaftesbury Place. Risk assessments encourage and support people living at the home to challenge and deal with problem areas in their lives. Care needs to be taken to ensure that confidential information is stored securely. EVIDENCE: The care for three people was case tracked, including two people who had moved into the home in February 2006. Comprehensive care plans are in place, which provide a holistic overview of the needs of people living at the home. Care plans indicate that areas of support needed should be highlighted Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 11 from the assessment. However it was not evident what assessment tool is being used. Staff were unable to provide this information. A comprehensive assessment tool is being used for admission purposes. A similar assessment would be appropriate. This assessment would then be used to identify and monitor people’s changing needs feeding into their care plans. There was evidence that care plans are being regularly reviewed and that annual reviews are taking place occasionally including representation from the placing authority. People living at the home are signing their care plans and have copies of a key working file in their room. Staff explained that these files have just been introduced and they are waiting for guidance and training on how they should be completed. Staff are requested to sign when they have read care plans. A number of staff had not completed this for the plans examined. Care plans have an amendment sheet to indicate when there have been changes to need. These are being used but not always appropriately. Entries did not always relate to needs identified in care plans for instance a healthcare appointment was recorded which did not relate to any specific changes in need. Discussions with staff on duty during the visits confirmed that they have a good understanding of the needs of people living at the home and how they wish to be supported. Agency staff confirmed that they have access to care plans and were observed completing daily records. Comprehensive daily records are kept for each person at the home in addition to monitoring forms for pressure sores, fluid and diet and continence. A handover was observed and the needs of people being case tracked were discussed referring to their personal and healthcare needs as highlighted in their care plans. People living at the home confirmed that they have regular house meetings for which minutes were available. These are displayed after the meeting in the lounge. People spoken to said that they feel that communication between management, staff and themselves has improved, with greater consultation taking place. Several said they had recently met the new area manager. A group of people living at the home recently attended a meeting with Sanctuary Care called ‘SHIRE’. This forum enables people using Sanctuary Care (formerly with Ashley Homes) to meet with management and other people using services to discuss issues of importance to them. Some people living at the home have advocates and a number of people are involved with Gloucestershire Lifestyles which provides advocacy as well as a social outlet. Robust records are in place for the management of personal finances. Regular checks are carried out and people living at the home are involved in either Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 12 observing or countersigning any money taken out. Protocols are in place for the use of people’s personal cash cards. It was noted that some people are using store reward cards. Staff indicated that the home has its own card which people living at the home may choose to use when making personal purchases. This is not good practice. Receipts for one person indicated a card had been used several times but not on other occasions. If people wish to use a reward card these must be obtained for each individual person. Risk assessments are in place that are being regularly monitored and reviewed. During the visit one person who lives in the flats on the first floor supported another person living at the home to go out to the local shops. Staff indicated that a risk assessment needed to be put in place for this. Another person has a friend who visits from their previous placement and they go out together. This should also be risk assessed with both parties. The missing person’s folder contains information including a photograph of people living at the home. This needs to be updated to include information about people who have recently moved into the home. At the time of the inspection cabinets containing information about people living at the home were unlocked. Staff indicated that these would normally be locked but at no time during the two visits were these cupboards or the offices locked. A room on the first floor that contains archived information is also unlocked. Confidential information about people living at the home must be stored securely. Staff were observed discussing personal information confidentially during the visits. Discreetly closing doors to rooms or the office. This is good practice. Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home who are independent have the opportunity to take part in a range of activities and lead a fulfilling lifestyle. The lives of people requiring support would be further enhanced by providing similar opportunities. Contact with family and friends is encouraged and supported. People living at the home are encouraged to maintain a healthy diet by giving them informed choice about the options available. EVIDENCE: People living at the home have access to a range of daytime activities including attendance at local colleges and day centres. One person who had moved into the home in February said that they are waiting for the college to arrange an interview with them. Staff confirmed that discussions were taking place about appropriate courses. Records of a review in May 2006 indicated that this was an identified need. Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 14 Activity schedules are in place confirming attendance at colleges and day centres. They also indicate that for people requiring staff support there is not much scheduled activity apart from shopping for food. Staff and people living at the home verified this. Some people are extremely active going out into the local community using the shops, cafes, pubs and library. They do not however require the support of staff. They said that they use local taxis and the community transport system if needed. Staff said that a restructure of the staff team is taking place and that an activities co-ordinator would be appointed on flexible hours to support people to access more activities outside of the home. It was not possible to ascertain whether any progress has been made in relation to financial contributions towards holidays. Previously there were inconsistencies in the way in which holidays were funded for individuals. A requirement was made that this should be clarified and recorded in their files. People living at the home have access to the home’s mini bus. If they need the bus they book the journey and are charged per mile. This appears to work well. People living at the home have been discussing fund raising for a new vehicle. The driver said that the bus had recently had an overhaul but would soon need replacing. During the visits some people were observed going to the local shops with the support of staff and one person was supported to go for a walk. People living at the home said that they had recently been to Burford Wildlife Park for the day and a group of them had been out for a meal. One person said they had enjoyed a day out at a local music festival. People living at the home said that they have regular contact with family and friends. One person had just visited their family and another was planning a holiday with theirs. Another person said that their family are able to visit them frequently because they now live nearer to them. Staff commented that there is not always sufficient space for people to meet with friends and family in privacy. People living at the home have access to a small communal dining room and kitchen in their units and the larger communal lounge or their rooms. Many rooms do not have chairs due to the space confinements for people using wheelchairs. The acting manager stated that a small room which is also an office can be used by prior arrangement. Consideration should be given to providing private space for people to meet with family or friends if they wish. People were observed using the laundry and preparing meals in their kitchens. Support is provided from staff if required. People were also observed choosing where to spend their time and with whom. One group were supported by staff to play a game in the garden, others spent time in their rooms or in the Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 15 communal lounge. Staff were observed treating people with respect and sensitivity. People living at the home are supported to plan menus for the week and then shop for the ingredients. Some people require support to cook their meals and this is provided. Where there are concerns about the diet of people monitoring records are maintained for fluids and solids. Staff said that a dietician would be visiting the home to advise staff and residents about a nutritional diet. Staff provide advice about a healthy and nutritional regime but people do not always choose to accept this. There was evidence of fresh vegetables and fruit in the units. Staff presently record each person’s meals for the day in the daily notes. There is inconsistency in the recording with some comments such as ‘ate a good meal’ or ‘usual breakfast’. If meals are to be recorded in daily notes they need to provide a record in ‘sufficient detail to enable any person inspecting the diet to determine whether the diet is satisfactory’. (Schedule 4.13) A team leader instructed staff to do this during the visits. Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 16 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The way in which the people living at the home would like to be supported is clearly recorded and managed ensuring that staff are able to meet their personal care needs. People living at the home have access to healthcare professionals and to a satisfactory medication system, making it possible to meet their healthcare needs. EVIDENCE: Staff and people living at the home confirmed that a key worker system is now in place. Copies of key worker files are kept in people’s rooms. These are not yet being widely used. People living at the home spoke positively about their key workers. Care plans clearly indicate the way in which people would like to be supported with their personal and healthcare needs. These are written in the first person and signed by people living at the home. Agency staff confirm that they have access to this information and discussion with them verified their understanding of the needs of people living at the home. Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 17 People living at the home described how they notify staff each day at what time they would like to get up and go to bed and whether they wish to have a bath. They said that this works efficiently. One person said that they have a bath twice daily. Staff confirmed that people have regular access to other healthcare professionals such as occupational therapists and physiotherapists. Several people have just received new wheelchairs. One person showed how the chair worked and was obviously delighted with its manoeuvring ability. Comprehensive health care records are being kept with outcomes of appointments. These confirmed that people have access to their Doctor, Optician, Chiropodist, Dentist and outpatient appointments. The diary records appointments that are also referred to in daily notes. Medication administration systems were examined. These are satisfactory. People living at the home have signed consent forms to have medication administered. A homely remedies policy and procedure is in place. Homeopathic remedies were prescribed for one person and staff immediately checked with the Pharmacist that these would be safe to take. The systems for people self-medicating were also examined. Lockable safes are provided in their rooms and checks are in place to ensure that medication is taken regularly. Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 18 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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are handled objectively and the concerns of people living at the home are acted on and recorded. There are vulnerable adults procedures in place and staff training is given in their use, providing staff with the knowledge and awareness to recognise and report incidences of abuse. EVIDENCE: The home has a complaints policy and procedure produced by Sanctuary Care that is displayed in the lounge. This document refers to a complaints leaflet for people living at the home that was not available in the home at the time of the inspection. One of the team leaders was attending a conference with Sanctuary Care on the day of the second visit to the home and was expecting to be given Sanctuary Care documentation including the complaints leaflet. This will be revisited at the next inspection. There was evidence that people living at the home are supported to make complaints and that these are dealt with by the team. Actions taken are recorded. People living at the home said they would talk to their key workers or to team leaders if they had any concerns. People spoken to also found the house meeting a useful venue for talking to team leaders about their concerns. Staff have attended training in the protection of vulnerable adults and those spoken with have a good understanding of their role in protecting people living at the home from possible abuse. The home has worked closely with the Gloucestershire Adult Protection Team in the past with a satisfactory outcome. Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 19 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is homely and comfortably furnished. Further environmental improvements to the property will ensure that the accomodation continues to meet the needs of people living there. EVIDENCE: Shaftesbury Place provides purpose built accommodation for people with a physical disability. People have a single room with access to a shared bathroom – most baths are assisted and two have Jacuzzi facilities. People share a kitchen/diner and have access to a communal lounge. To the rear of the home is a courtyard. On the whole the home is well maintained. A member of staff is employed to oversee the day-to-day maintenance. The kitchens have needed renovating for some time. They were repainted and doors were mended two years ago. Maintenance of these is ongoing – at the time of the visit a drawer needed replacing. Team leaders indicated that they have budgeted for kitchen units to be replaced in the forthcoming year. This work must be completed. Fridges and freezers have also caused ongoing concerns. Handles have been replaced as they have broken. Two fridges had broken handles that were identified in the maintenance plan. Several fridges Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 20 also had an unpleasant odour due to age. These must be replaced. It is important when these alterations are completed that fixtures and fittings are accessible to people with a physical disability and to people who use wheelchairs. The fridges presently in use are not accessible to all people living at the home in some cases increasing people’s dependence upon staff. A health and safety audit was completed in December 2005 and identified that the sheds in the garden needed attention or removing. Examination of these sheds confirmed that they are a health and safety risk. They must either be renovated or removed. Other environmental issues noted during the visits included: Units 1-4 • • • Damage to toilet wall needs repairing Plasterwork near new fan needs attention Fridge handle needs replacing Units 5-8 • • Damage to toilet wall needs repairing Plasterwork near new fan needs attention Units 9-12 • • • Damage to kitchen wall needs attention Fridge handle needs replacing Damage to toilet wall needs repairing Units 13-16 • • Broken drawer needs mending Fridge handle needs replacing At the last inspection one person living at the home was wishing to move into another flat on the first floor. They were away at the time of this visit but staff said that the move had taken place successfully. As a result of this move a condition was added to the registration of the home. At the time of the visits the home was clean and tidy. Correct procedures were being followed in the laundry. Red bags are provided for soiled laundry. People living at the home and staff use the sluice room, which was satisfactory. Personal protective equipment is provided for staff. Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff have a good understanding of the support required by people living at the home and this is evident from the positive relationships, which have been formed with staff. The standard of vetting and recruitment procedures need to be improved to ensure that they are protecting people living at the home from the risk of harm or abuse. The provision of training for staff is improving providing a staff team who have the necessary qualifications to support people living at the home. Access to National Vocational Qualifications could be better. EVIDENCE: A new member of staff had started working at the home on the day of the first visit. She had started an induction and confirmed that she would be shadowing staff for the first month. She was observed having an introduction into fire procedures at the home and reading care plans. Agency staff also confirmed that they complete an induction. Copies of their induction are kept at the home. Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 22 Six members of staff have a NVQ Award in Care. This falls short of the recommended 50 of care staff to have a NVQ Award at Level 2 or over. Sanctuary Care needs to ensure that systems are in place for staff to access these awards. A number of new staff have been appointed and applications are being processed for other new staff. There are presently four full time vacancies for which interviews are being scheduled. People living at the home were observed being part of the interview process during one of the visits to the home. This is good practice. Team leaders said that they have not completed training in recruitment and selection. This must be provided to staff involved in this process and ideally for people living at the home. Staff files were examined for two new members of staff and several prospective members of staff. When processing applications staff must ensure that the following issues are dealt with: • • • • • Any gaps in employment history are questioned and evidence provided of the reason for the gaps – the application form requests this information but this was not always being supplied where people have previously worked with adults or children the reason for leaving this employment must be obtained in writing, wherever practicable information supplied from the Human Resources Department must indicate whether an enhanced or standard check has been completed – for all care staff this must be at an enhanced level arrangements should be made for Commission for Social Care Inspection to sample CRB checks on an annual basis any staff working with a povafirst check and without a CRB check in place must have a risk assessment in place detailing the support they receive from the home until the check is received (staff confirmed that a named person was responsible for the person and that they would shadow staff until the check was obtained). photographs of staff must be obtained. • The pre-inspection questionnaire listed training provided which included boundaries and confidentiality, equality and diversity, mandatory training, supervision training, risk assessment and medication training. Future training is planned for infection control and COSHH, learning disability and moving and handling. Copies of certificates are kept on staff files. Staff confirmed that they have access to regular training and refresher courses. Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 23 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): 37,39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home are benefiting from significant improvements in systems and processes within the home. These will be further enhanced by the appointment of a registered manager. The home’s quality assurance programme involves people living at the home in the review of services being provided. Systems are in place enabling the home to provide an environment that promotes the welfare and safety of people living there. EVIDENCE: After a succession of temporary managers, the team leaders have been managing the home until recently when one of them was promoted to acting manager. Interviews take place in June for the position of manager. Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 24 The large number of requirements is indicative of this situation although the team have worked hard to significantly improve standards in the home over the past nine months such as implementing and maintaining a new care planning system, financial recording and health and safety records. People living at the home say that they feel more confident and comfortable than at previous inspections. It was noticeable that no concerns about the quality of their care were expressed during this inspection. This is a considerable improvement from previous inspections. As mentioned people living at the home took part in a forum with Sanctuary Care to discuss their experiences with people from other services and the management of the organisation. Monthly-unannounced visits are in place and a record is sent to the Commission. These involve people living at the home. A quality assurance audit was conducted in December 2005 that highlighted areas for concern and areas of good practice. People living at the home were involved in this. A maintenance audit is also completed annually. The staff member responsible for general maintenance keeps comprehensive health and safety records. These confirmed information supplied in the preinspection questionnaire that health and safety checks are carried out regularly. Staff complete mandatory training including fire training. Staff are reminded to carry out a night fire drill as part of this process. Staff were unable to confirm whether this had been done. Fridge and freezer temperatures are taken although there is some inconsistency between units. These must be taken daily. Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 25 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 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 2 X Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4(2) 5(2) 6(a)(b) Requirement The registered person must ensure that the Statement of Purpose and Service User Guide are reviewed. Copies of these documents are to be provided to the Commission and made available to service users. The registered person must ensure that each person has an assessment and that this is kept under review. The registered person must ensure that staff receive training appropriate to the work they perform in particular in relation to care planning and key working. The registered person must ensure that professional relationships are maintained between staff and service users, and that valuables such as reward cards for individuals are used appropriately and kept safely. The registered person must put risk assessments in place as detailed in the standard. The registered person must Timescale for action 31/08/06 2. YA6 14(2) 31/08/06 3. YA6 18(1)(c)(i) 31/08/06 4. YA7 12(5) 16(2)(l) 31/08/06 5. 6. YA9 YA9 13(4)(c) 13(4)(c) 30/06/06 30/06/06 Page 27 Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 7. 8. YA10 YA12 9. YA14 10. YA17 11. YA24 12. 13. YA24 YA24 14. YA32 ensure that the missing person’s information is updated to include information about service users who have recently moved into the home. 17(1)(b) The registered person must ensure that information is stored securely in the home. 16(2)(m)(n) The registered person must ensure that service users have the opportunity to access activities and lead a fulfilling lifestyle. (Timescale of 31/03/06 extended). 17(2) The registered person must Sch 4.9 review the way in which financial contribution towards holidays is made, and keep a record of this. (Timescale of 19/10/05 not met) 17(2) Sch The registered person must 4.13 ensure that a record of food provided is in sufficient detail to assess whether the diet is satisfactory. 23(2)(a)(b)(c) The registered person must ensure that the kitchens are fit to be used: • Units are to be replaced • Fridge and freezers to be replaced • These must be appropriate to meet the needs of people with a physical disability. 13(4)(c) The registered person must 23(2)(c) ensure that the sheds are either renovated or removed. 23(2)(a)(b)(c) The registered person must ensure that environmental issues identified in this standard are actioned. 18(1)(c) The registered person must ensure that staff have access to the training they require to perform their work: • NVQ Awards DS0000067461.V291928.R01.S.doc 30/06/06 31/08/08 31/08/06 30/06/06 30/06/07 31/12/06 31/12/06 31/12/06 Shaftesbury Place Version 5.1 Page 28 15. YA34 19(1) Sch 2.1,4,6 17(2) Sch 4.6 16. YA42 13(4)(c) recruitment and selection training. Information in respect of staff working at the home must be obtained in line with Schedule 2 and records kept in the home in line with Schedule 4. A night time fire drill must be put in place. Fridge and freezer temperatures must be taken daily. • 30/06/06 30/06/06 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. 2. 3. 4. Refer to Standard YA6 YA15 YA34 YA34 Good Practice Recommendations Copies of reviews should be kept on main files so that they are accessible to key workers. Consideration should be given to making private accommodation available for people to meet with family or friends. People living at the home involved in recruitment and selection should receive appropriate training. Arrangements should be made for Commission for Social Care Inspection to sample original CRB documents annually. Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shaftesbury Place DS0000067461.V291928.R01.S.doc Version 5.1 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!