Inspection on 20/03/08 for Shakespeare Way (4)

This inspection was carried out on 20th March 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shakespeare Way (4) 28/01/09

Shakespeare Way (4) 15/08/06

Shakespeare Way (4) 01/03/06

Shakespeare Way (4) 01/12/05

Shakespeare Way (4) 28/02/05

Shakespeare Way (4) 25/01/05

Shakespeare Way (4) 26/03/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 Shakespeare Way (4) Aylesbury Bucks HP20 1JF Lead Inspector Jane Handscombe Unannounced Inspection 20 & 23 March 2008 10:30 th rd Shakespeare Way (4) DS0000023049.V359439.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 Shakespeare Way (4) DS0000023049.V359439.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. Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shakespeare Way (4) Address Aylesbury Bucks HP20 1JF 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) 01296 426332 jackieaklippel@yahoo.co.uk www.macintyrecharity.org MacIntyre Care Miss Jaqueline Klippel Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th August 2006 Brief Description of the Service: 4 Shakespeare Way is situated a short distance from the town centre of Aylesbury, where a variety of shops and other local amenities can be found. The town is served by local public transport, including rail and bus links. Bus routes pass within walking distance of the home. 4 Shakespeare Way is run by MacIntyre Care who are a well-established provider of a range of day and residential care services for adults and young people with learning disabilities. The home provides accommodation for up to six adults with learning disabilities. The home works with service users who have developed moderate levels of independent living skills so that the role of staff is essentially one of support and guidance, rather than direct provision of care. The home comprises two linked semi-detached properties that offer single bedrooms to each service user, along with communal lounge, kitchen, dining and laundry areas. At the time of this inspection there were five service users in residence. Fees for placements at the home currently ranged from £37,292 to £40,390. Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes This was a short announced visit in which the service was informed the evening previous to our visit of our intention to visit the following day. The visit took place on the 20th and 23rd March. On the first day we were accompanied by an ‘Expert by Experience’, a person who has received a similar service, and who is trained to help us carry out our inspections. The purpose of the visit was to see how the home is meeting the National Minimum Standards. The home currently provides support to 6 service users. All of these users were sent questionnaires in order to ascertain their views upon the support they receive, and responses were received from all 6. Likewise surveys were forwarded to the three permanent staff and eleven health care professionals to gain their feedback. Whilst feedback was received from the staff, at the time of writing this report the feedback results from the healthcare professionals were not available at the time of writing this report. They will however, be considered as part of CSCI’s ongoing regulatory responsibilities for the registered service. Results of this inspection report are derived from feedback gained from the service users, discussions with staff during the visit, viewing client’s records held within the service, viewing policies and procedures, staff personnel files, general observation throughout the day, along with any information that CSCI has received about the service in order to gain an understanding of how the services provided by the agency meet the service users’ needs, and impact upon their lives. We looked at how well the home was meeting the standards set by the government and have in this report made judgements about the standard of the service. Comments received from those using the service include: ‘I’m happy here, the staff are very good’ I go swimming and I do cooking and shopping’ ‘We help keep our house tidy ‘staff help me do things’ ‘staff explain things to me Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 6 Wewould like to thank all those who gave their time during the inspection process. What the service does well: What has improved since the last inspection? What they could do better: There are a number of areas relating to the health, safety and welfare of those using the service for which requirements and recommendations have been made within this report to ensure the health, safety and welfare of those using the service and to ensure the service is working in their best interests, which are namely that of: Ensuring that details within all the service users files are accurate and kept up to date. Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 7 Ensure that all medication, which has a short shelf life, is dated when opened to ensure the health safety and welfare of the service users. Repairs to be undertaken in the bedroom and bathroom as indicated in this report to provide more comfortable surroundings for people living at the home, The practice of sharing bars of soap must cease to ensure that people are not placed at risk from cross infection. Ensures all generic and individual risk assessments are brought up to date to ensure the health safety and welfare of those using the service. Follow the Royal Pharmaceutical Society’s guidelines and appropriate entries be made in the home records detailing the medicines the service users take out of the home with appropriate risk assessments in place to ensure the health, safety and welfare of those using the service. It is good practice to renew CRB checks every three years. 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. Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 8 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 Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 9 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 and 3 Quality in this outcome area is good. Prospective users of the service undergo an assessment of needs and are invited to visit the home, staff and fellow users of the service to ensure that both parties are confident that their needs can be met appropriately at Shakespeare Way. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Prior to being offered a placement at 4 Shakespeare way all prospective users of the service undergo an assessment of needs, which is undertaken by the registered manager and a senior member of staff. They are then offered introductory visits to the home to meet with fellow users of the service and staff members to ensure that the placement is suitable for all parties concerned. The views of the current service users are also taken into account. Documents relating to the last person admitted to the service were read and showed that information had been sought from his previous placement before the person came to live at the home and a needs assessment was undertaken with Bucks County Council to enable the service to assess whether they could meet the persons needs appropriately. Likewise, the person had been invited to spend some time at the home meeting with fellow users of the service and Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 10 staff members – this included overnight stays, allowing the service to assess the prospective users needs to ensure that all parties were confident that the placement was suitable. The said person in discussion verified this with the inspector during this visit. People using the service who completed comment cards said that they had been involved in the decision to move into the home and had been given sufficient information about it beforehand. From the evidence seen by the inspector and comments received, the inspector considers that whilst the service does not currently have any service users from an ethnic minority or similar background, this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 11 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, 8 and 9 Quality in this outcome area is adequate All those using the service have a plan of care but information held within them is not always accurate and up to date. People using the service are enabled to make decisions about their lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The last two inspections identified a series of shortfalls in the provision of up to date and accurate care plans and information about service user care needs, for which requirements were made. During this visit we looked at two service users files, one a long-standing user of the service and the other having been admitted since the last inspection. It was noted that the long-standing service users’ file contained risk assessments relating to a previous MacIntyre service. Within the file was documentation, which stated the service user, rides a Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 12 bicycle, which the manager informed us during discussion that he/she no longer rides a bicycle. Likewise there was an entry stating ‘I want to go on a healthy diet to help me with my weight’ dated 6th January 2008. Whilst viewing this persons files, there was no mention as to how this had been followed up, there was no evidence of any dietician input and there was no mention in the service users health action plan as to how this request was to be followed up. In discussion with the manager it was ascertained that the service user did not wish to have any dietician involvement and that the user keeps changing his/her mind about wanting to go on a healthy diet, although there was no written evidence within the file to support this. Likewise other documentation within the file dated 2005 informed us that the service user was in a relationship, yet upon speaking with the manager, this was no longer the case. A repeated requirement with new timescales has been made within this report to ensure that details within the service users files are accurate and kept up to date. Feedback from surveys sent out to those people using the service, prior to our visit, said that they can usually make decisions about what they do each day although comments made to our expert by experience showed some dissatisfaction with the day service placement they attend during the week. It was felt that the activities they were to take part in, were organised by the day service. This was feedback to the manager who informs us that she will speak with the service users and deal with any concerns they may have appropriately. All of the people living at the home had keys to their rooms to ensure privacy. People using the service exercise responsibility with support in the planning, preparation and serving of meals as well as undertaking household chores and rotas are drawn up to undertake the tasks. Menus are displayed in the home in picture format and the household task list is displayed in the home, also in picture format. The planning of holidays is undertaken with those using the service, gaining their ideas and choices of what they would like to do and where they would like to stay. The week following this visit all those using the service are taking a holiday; three chose to take a holiday in Minehead, whilst the remaining three have chosen to take a holiday in Clacton. House meetings are held every two months giving those who use the service the opportunity to voice their opinions and contribute to the running of the service. These meetings are minuted and documented within the home. Likewise a staff member informed our Expert by Experience that meetings with residents’ and staff are held every fortnight, she said that they talk about their safety in the home and also do fire drills after the meetings. Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. Opportunities for residents to take part in a variety of interesting activities and to keep in touch with family and friends are good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People using the service have varied lifestyles reflecting their individual interests and offering them the opportunity to try new experiences. Details within the care plans, daily notes and feedback from service users and staff evidenced that all are actively involved within the local community attending day service placements, and undertake voluntary work in the local area. On the first day of this visit, five users of the service were out attending a day service whilst one service user chose to remain within the home. Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 14 The majority of service users attend MacIntyre day care services in Milton Keynes during the week, which arranges the service users daily activities offering them opportunities in different areas (garden centre, coffee shop, bakery etc) to work with other people and meet the public in constructive employment roles. However one service user in discussion with the Expert by Experience said he did not like going to the day centre, so chooses to go to a local garage instead which he/she instigated independently. Discussions with the manager and evidence within this service users file informs us that staff are supporting him/her to pursue the interest further and are working in conjunction with his/her care manager to find a placement where he/she can learn more about mechanics. People using the service are supported to follow personal interests and activities. One service user has an interest in cats and enjoys helping out, one day a week, in a local cattery and also helping in a local school in the reception area. Arrangements for service users to meet with friends and family members are flexible and support is given to maintain personal relationships where required. Residents’ independence is promoted both within and outside the home. One resident attended his Doctor’s appointment on his own while we were at the home whilst another resident was doing her washing in the laundry room without any supervision or prompting. Whilst the home generally promotes independence and choice around home in choice in food menus, holidays and outings, this was not the case with regard to the evening meal on our first days visit. It was noted those using the service were to have a take away meal in the evening and were asked if they wanted a Chinese take away meal or fish and chips. Two of them wanted fish and chips, whilst the others wanted a Chinese meal; rather than provide for their individual preferences and choices, the member of staff tossed a coin to decide upon what they were all to have. Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate Information needed by staff to be able to provide personal and health care support was included in residents’ files, although there was some documentation in the files viewed that was not completed and left blank. Staff help residents to look after their own medication although poor practices are taking place, which could compromise the health, safety and welfare of those using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of the inspection process, we chose to case track two service users one of who was admitted since the last inspection and the other relating to a service user who had been at the home for a longer period. Care and support plans were in place for each person living at the home which were individualized and detailed how they wish to be supported, although there was some documents that had not been filled in and left blank. It was evident that the service understands that people using the service may want access to Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 16 someone of the same gender to assist and support in personal intimate care and an intimate care policy was held in their files informing of their preferences to ensure their preferences are upheld. Summaries of appointments with health care professionals were documented within each users file. The former service users’ file contained a number of documents that remained blank and had not been completed since he/she was admitted in September 2006. These included documents headed ‘medication that I take’, History of the medications I have taken’, ‘Injections I’ve had to protect me against disease’. and ‘Goals to improve my health’ Furthermore, from viewing correspondence with health care professionals and discussions with staff, it was ascertained that the service user presents with some challenging behavior, although no risk assessment had been undertaken in relation to his/her challenging behavior. The lack of completed documents fail to give a full ‘picture’ of this individuals health care needs and must be addressed to ensure that his/her needs are being met appropriately. The second file viewed evidenced that regular reviews had been undertaken and involved family members and other relevant health care professionals. However the file contained information, which was out of date (see section headed individual needs and choices) and the document headed ‘the medication that I take’ was not completed and left blank. It was further noted that the service user has a medical condition which gives rise to seizures yet no risk assessment had been put in place relating to the seizures and no information was documented detailing what staff were expected to do when a seizure occurred. A requirement has been made within this report to address the above shortfalls. During this visit, it was evident through discussion with the manager and from observation of files that individual risk assessments were not yet brought up to date, although work was in process in this area. A new risk assessment format has replaced the older format and the manager was observed to be attending to some of these during the inspection. Since a recommendation was made to ensure that all generic and individual risk assessments be brought up to date at the last inspection undertaken in August 2006, and the lack of appropriate risk assessments evident in relation to the files viewed on this visit, a requirement has been made within this report to ensure that all generic and individual risk assessments are completed within a given timescale to ensure the health, safety and welfare of those using the service at all times. Users records viewed during the inspection indicated evidence that their views and preferences are taken into account when providing care and support. Staff are provided with training in safe medication practice and the policies and procedures for dealing with medication serve to protect the service users Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 17 health, safety and welfare. Medication was stored safely and the medication administration records were found to be in good order. Whilst viewing the medication storage it was noted that prescribed creams, which have a short shelf life after opening, did not alert staff to the date of opening. The said cream had been dispensed in May 2007. A requirement has been made within this report to ensure that all medication, which has a short shelf life, is dated when opened to ensure the health safety and welfare of the service users. In discussion with the manager, it was noted that the service users were all taking a holiday the week following this visit and a recommendation was made to follow the Royal Pharmaceutical Society’s guidelines and appropriate entries be made in the home records detailing the medicines the service users take out of the home with appropriate risk assessments in place to ensure the health, safety and welfare of those using the service. Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. There are complaints and safeguarding policies and procedures in place to protect service users and enable them to raise any concerns. People using the service and those close to them; know how to complain if the need should arise. Their concern is looked into and appropriate actions are taken. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Systems are in place for managing service user’s personal allowances. Small amounts of cash are kept for each resident in the home and records of expenditure and receipts are kept and logged. The inspector viewed the financial documentation of the service users who were case tracked during the inspection. Monies were found to be stored safely and securely all financial transactions were well documented, receipts kept and all were found to be accurate. There is a complaints procedure in place which is accessible to all those using the service and their families, which has been produced in various formats to suit the needs of those using the service. Feedback gained from those using the service informs us that they know how to complain and who to go to with any concerns if the need should arise. Any concern is looked into and appropriate actions are taken to put things right. Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 19 Each user of the service has an individual book in which any concerns or complaints are logged and appropriate actions are taken. However, there was evidence of one inappropriate entry, which stated that the service user had toothache and staff had given analgesia to help with the pain. This clearly is not a complaint/concern about the service or the provision of care. In discussion with the manager it was recommended whilst users of the service have an individualised concern/complaints book, a central complaints book for the service would enable easier auditing of complaints and allow for any complaints from family members or other stakeholders to be logged, along with the actions taken and the resultant outcome. The service has received one complaint in which they are supporting the service user to use the homes formal complaints procedure, which is presently ongoing. The commission have not received any direct complaints or concerns during the last 12 months. Staff who completed comment cards said they are aware of what to do if people raised any concerns about the home. The home has an up to date copy of the Buckinghamshire’s multi agency policy and procedures for the protection of vulnerable adults and all staff are provided with relevant training both in their induction training and regularly thereafter, enabling them to recognise the signs of abuse and how to respond if an allegation or incident is brought to their attention. The commission has been notified by the service of three safeguarding incidences, all of which were referred to the appropriate bodies and dealt with appropriately. Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 20 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, 25 and 30 Quality in this outcome area is adequate. The physical design and layout of the home enables people to live in a safe environment. Bedrooms are decorated and personalised to service users individual choices and preferences. The home is not readily accessible to wheelchair users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is not readily accessible to wheelchair users, there are no ramps to enable easy access and there is no lift, service users and their visitors have to be able to use the stairs to access the upstairs bedrooms. The home is situated in a residential area and blends in with the surrounding houses. It comprises of two linked semi-detached properties that offer single bedrooms to each service user, with a bathroom and toilet upstairs on each Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 21 side and a toilet downstairs. There is a communal lounge and dining area and a good-sized kitchen, which leads to the garden through patio doors. Service users and their visitors can enjoy the outside lawned garden and built in barbeque in the warmer months. The gardens were found to be tidy and accessible to those using the service. It was noted that the seating arrangements in the lounge did not provide comfortably for all those living there; it consists of two -2 seater settees for the 6 residents which if all wished to use the lounge left some with no choice but to sit in the dining room adjacent to the lounge or go to their bedrooms. However, this did not appear to cause problems during this visit, although is an area that could be improved upon. Each service user has their own bedroom; none of which are shared and all are lockable to allow for privacy. The overall condition of bedrooms could not be judged, as most people were out or unavailable to show their rooms, although we did accompany one service user who showed us their room which was equipped and decorated to the service users individual taste and preference. However, it was noted that repairs were required in this particular bedroom in which there was damage to the wardrobe in which one of the doors had a large hole in it and damage was also apparent to part of the wall. A further hole was noted one of the communal toilet doors. This was fed back to the registered manager who informs us that these will be dealt with and be repaired. Toilets were stocked with all necessary items and were clean although a bar of soap was noted in one bathroom. The practice of sharing bars of soap must cease to ensure that people are not at placed at risk from cross infection. The interior presented as homely, clean and tidy and generally in good repair, other than those mentioned above, which we are assured are to be addressed. The laundry was separate from the kitchen and presented as spacious, clean and tidy. Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is good. There is a robust recruitment procedure to ensure suitable staff are employed to work at the home. The arrangements for the induction of staff and training are good with staff demonstrating a clear understanding of their roles. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions around staffing levels informed us that there are three permanent staff presently working at the home who are supported by a further three staff supplied by an agency and staff from other MacIntyre services help when required. The manager explained that two staff have left the service although they are presently advertising to recruit for more staff. The contents of staff personnel files evidenced that there is a robust recruitment and selection procedure, which acts to ensure the service users health, well being and security. Application forms are completed, references are collected and a face-to-face interview is undertaken. Relevant POVA (protection of vulnerable adults) and CRB (criminal records bureau) checks are undertaken prior to appointment to ensure the persons suitability with working Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 23 with vulnerable people. It is a good practice recommendation to renew CRB disclosures every three years. Feedback received from staff provided evidence that they felt their recruitment was done fairly and thoroughly. All newly recruited members of staff receive a structured induction training including shadowing more experienced carers until both parties feel confident and comfortable. Staff are provided with mandatory training in core subject areas which is updated accordingly, and undertake ongoing development in order that they are appropriately trained and equipped with the skills to meet the varying personal care needs of the service users, thereby protecting the service users health, well being and safety. Staff training is recorded in individual staff files and those viewed demonstrated the home’s commitment to staff development and training. All staff are encouraged to undertake the National Vocational Qualification (NVQ) at level 2 or above in care. Of the three permanent staff two have NVQ level 2 or above and the newer member of staff will be registered to undertake the qualification when she has successfully completed her probationary period. Feedback from staff was very positive, they said that the manager gave them enough support and meets with them regularly to discuss how they are working, evidence of which was found within those staff personnel files viewed during this visit, and annual appraisals, although not yet due, have been planned for accordingly. There was evidence that regular staff meetings are held and the staff spoken to said that they felt involved in the home and that their views were respected. Staff said there was usually enough staff to provide support, with the use of some agency staff in recent times. A look at recruitment files showed that all necessary checks are undertaken before people start working at the home, including those agency staff being supplied to work on a regular basis. During the visit it was apparent that the staff have a clear understanding of their roles and responsibilities and demonstrated a good sense of teamwork. Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 24 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, 41 and 42 Quality in this outcome area is adequate. People using the service are provided with a safe environment in which to live. Evidence of poor procedures taking place namely around record keeping for some of the key document tools such as care plans and risk assessments do not serve the service users best interests and could compromise the health safety and welfare of those using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Well-maintained health and safety records are kept in the home and were made available for inspection; a range of these were viewed and documented appropriately. Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 25 The home has a quality assurance system in place. The manager confirmed that an operational manager visits the home regularly to undertake a quality assurance review; the visits are documented and held in the home. Regular formal feedback is gained from service users and their family members to ascertain their views on the provision and any areas in which improvements could be made. A recent questionnaire has been sent to service users, family members and other stakeholders to gain their views on the provision of the service, the results of which have not yet been collated. However the manager assures us that the feedback gained will be used to inform the service on areas for improvement and acted upon appropriately. The service focuses on the individual, takes account of equality and diversity issues, and generally works in partnership with families or close friends, as appropriate, and professionals. Feedback from staff informs us that the manager is approachable, she runs the service in an open transparent manner, and any concerns that they may bring to the managers attention will be dealt with appropriately. The manager sent us the Annual Quality Assurance Assessment (AQAA) within the timescales and has recognised areas in which improvements are to be made over the next 12 month, to improve outcomes for those using the service. Whilst the manager does not yet hold the Registered Managers Award qualification or the NVQ level 4 in care (or equivalent) this means that Standard 37 cannot be assessed as ‘fully met’ until these qualification are obtained. We are informed that she is presently in the process of applying to undertake the Registered Managers Award and NVQ level 4 in care at a local college. Previous applications were not undertaken due to the courses being cancelled. Users of the service generally receive good outcomes, however the shortfalls around individual risk assessments and incomplete documentation within service users files (see section headed personal and healthcare support) do not serve the best interests of those using the service to ensure their health, safety and welfare. The insurance cover for the business, professional and public liabilities, protects Service users and staff. Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 26 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 3 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 x 27 2 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 2 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 2 2 x 2 x 3 x 2 2 x Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 27 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 YA6 Regulation 15(1) Ensure that details within all the service users files are accurate and kept up to date. Previous timescales of 31/05/06 and 31/10/06 not met. 2 YA20 13(2) Ensure that all medication which has a short shelf life is dated when opened to ensure the health safety and welfare of the service users. Ensures individual health care needs and information relating to service users is brought up to date. Repairs to be undertaken in the bedroom and bathroom as indicated in the report to provide more comfortable surroundings for people living at the home. The practice of sharing bars of soap must cease to ensure that people are not at placed at risk from cross infection Ensures all generic and individual risk assessments are brought up DS0000023049.V359439.R01.S.doc Requirement Timescale for action 11/05/08 11/05/08 3 YA19 12 11/05/08 4 YA24 23(2)b 31/05/08 5 YA27 13(4) 11/05/08 6 YA42 13(4) 11/05/08 Shakespeare Way (4) Version 5.2 Page 28 to date to ensure the health safety and welfare of those using the service. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA20 Good Practice Recommendations Follow the Royal Pharmaceutical Society’s guidelines and appropriate entries be made in the home records detailing the medicines the service users take out of the home with appropriate risk assessments in place to ensure the health, safety and welfare of those using the service. It is good practice to renew CRB checks every three years. 2 YA34 Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shakespeare Way (4) DS0000023049.V359439.R01.S.doc Version 5.2 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. 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