Inspection on 29/07/08 for Shawe Road Short Break Service

This inspection was carried out on 29th July 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Shawe Road Short Break Service 30/08/07

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Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 13/11/2008.

CARE HOME ADULTS 18-65 Shawe Road Short Break Service 10 Shawe Road Flixton Manchester M41 5DL Lead Inspector Kath Oldham Unannounced Inspection 29th July 2008 08:15 Shawe Road Short Break Service DS0000069192.V368981.R03.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 Shawe Road Short Break Service DS0000069192.V368981.R03.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. Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shawe Road Short Break Service Address 10 Shawe Road Flixton Manchester M41 5DL 0161 794 3764 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) jpilkington@iasservices.co.uk www.iasservices.info IAS (Services) Ltd Jill Pilkington Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of respite service only. Care home only - code PC, to service users of the following gender:Either. Whose primary care needs on admission to the home are within the following categories: Learning disabilities -Code LD The maximum number of service users who can be accommodated is: 6 Date of last inspection 30th August 2007 Brief Description of the Service: Shawe Road is a short break service, which has been established for a number of years, initially owned and staffed by Trafford Borough Council. In March/ April 2007 the temporary staffing of this respite service was awarded to IAS Services Ltd. Jill Pilkington from IAS Services Ltd manages the service and staff are employed directly by IAS. The property is owned by Trafford Council and responsibility for the upkeep of the building remains with the council. Shawe Road provides up to six short-term places for younger adults with learning and physical disabilities. Trafford Council determines the days allocated to the people using the service. Many of the people using this service have attended for a number years. The days allocated at Shawe Road range from overnight stays, a couple of days or longer periods. These times are chosen by the people using the service, their relatives or person providing support to them on a day-to-day basis and are usually booked in advance, in discussion with Shawe Road. The unit is situated in an established residential area, close to Flixton and near to public transport and other amenities. Shawe Road Short Break Service DS0000069192.V368981.R03.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 key inspection, which included a site visit to the service. This visit was unannounced, which means the managers and staff were not told we would be visiting, and took place on 29th July 2008, commencing at 8:15am until 3.30pm. Shawe Road provides short-term respite care for up to six people with learning difficulties. There are no permanent placements at Shawe Road. We looked at all available information received by us about the service since the last inspection. We also sent the manager a form before the visit for her to complete and tell us what they thought they did well, and what they need to improve on. We considered the responses and information provided and have referred to this in the report. We call this form the Annual Quality Assurance Assessment (AQAA). Shawe Road was inspected against key standards that cover the support provided, daily routines and lifestyle, choices, complaints, comfort, how staff are employed and trained, and how the service is managed. Comment cards were sent prior to the inspection for distribution to people staying at Shawe Road their relatives and staff, the views expressed in returned comment cards and those given directly to the inspector are included in this report. We found our information at the visit by observing care practices talking with people staying at Shawe Road; talking with the manager, team leader, and staff. A tour of Shawe Road was also undertaken and a sample of care, employment and health and safety records seen. The main focus of the inspection was to understand how Shawe Road was meeting the needs of people and how well the staff were themselves supported to make sure that they had the skills, training and supervision needed to meet the needs of people. The Commission for Social Care Inspection has not received any complaints about this service. There has been one safeguarding matter reported to the Commission. There was evidence that the manager was managing the incident well; that Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 6 procedures were followed and the appropriate professional bodies were involved. The care service provided to two guests was looked at in detail to help form an opinion of the quality of the care provided. A brief explanation of the inspection process was provided to the staff on arrival at the home. Time was spent at the end of the day to provide verbal feedback to the manager and team leader. The term preferred by people using the service was “guests”. This term is, therefore, used throughout the report when referring to people staying at Shawe Road What the service does well: What has improved since the last inspection? Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 7 To promote best practice, staff who are trained and are competent to administer medication have detailed their usual signature and initials which accompanies the medication records. To safeguard guests and staff, a record is now made of the number of tablets brought into Shawe Road and the number leaving the home on discharge on the medication administration records. To safeguard guests and staff, medication brought into the home is in the original container or packet, which clearly indicates the time and frequency of medication administration. We were told that all staff who have the responsibility of administering medication have attained detailed medication training so they are aware of best practice and have a clear understanding of their responsibilities when administering medication. Staff do need to have their competency assessed by the manager as they have either not understood the training, not attended or are not all adopting safe and best practice. The manager has undertaken an audit of all rooms and removed a lot of the stored items and have tried through decoration of bedrooms and re carpeting present the rooms taking into account individuals’ dignity, privacy and self worth. There continues to be a need to further promote individuality of guests by ensuring other guests possessions are items belonging to Shawe Road are not stored within bedrooms. To safeguard guests, as recommended on the last inspection any gaps in employment are discussed with prospective employees and the reasons for leaving past employment are explored and this detail is recorded on the revised job application form. All equipment used at Shawe Road has been regularly serviced as identified in health and safety guidelines to ensure it is working properly and is safe for use this record is maintained at Shawe Road and was available for examination. The manager endeavours to ensure that monies belonging to guests is returned to them when they leave Shawe Road. We were told there may be occasions when guests forget and if it is a small amount and getting back to Shawe Road is inconvenient they may ask that the money is kept at Shawe Road for them until they next stay. We were told that all staff had received fire drill training practice and saw that staff sign next to their printed name when they have received training. What they could do better: The manager really needs to look at the care plans and risk assessments and make sure there is one in place and also make sure that these care plans Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 8 reflect the care and support guests need. The lack of detail within care plans can mean that guests do not get what they want when they need it. Staff know a lot of detail about particular guests which is not recorded. Therefore the service provided cannot be consistent, as some of this information is not passed on to other staff. A care plan was not in place for one guest who had been staying at Shawe Road for a week. The guest had not been to Shawe Road for over two years and the information they had on this guest dated from that time. This is not acceptable and this needs pulling together to ensure the theory, which the policies indicate, are transferred into practice. The specifics of the care provided needs also to be recorded in the care plan. The manager needs to look at the standards for direction in this matter. The manager needs to get some sort of menu in place to detail all the mealtime options and alternative choices. All nutritional assessments need to be detailed to inform staff about likes and dislikes and the way foods should be served. A system needs to be put in place, which, wherever possible, enables guests to be consulted over meals. The recording in the menus needs to be in place to show to guests, wherever possible, what is on the menu. There continues to be some development needed to the medication practices to make sure the practices are safe and promote guests’ health and welfare. Some of the recommendations from the last inspection have been addressed but others need the manager’s attention. The training we were told that staff had attended was not recorded. We were told that the systems to record this training were not up to date so it wasn’t clear what training staff had and hadn’t received. Some staff spoken to or who made comments in comment cards indicated that some training had been arranged for the future but had not yet been attended by them. To safeguard guests and staff this training needs to be arranged and an accurate record kept of this training. 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. Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 9 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 Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Guests’ needs are assessed prior to their stay at Shawe Road so the staff can be sure they can meet the personal needs of individuals. EVIDENCE: Trafford Local Authority arranges the assessment of people using the service. All guests have been coming to Shawe Road for a number of years and staff know their needs and aspirations. We were told on the last inspection visit that IAS had appointed an additional team leader to visit guests and their families to get additional information to assist them to support guests and provide care as they need. The manager said this had been done and all guests had been visited. Two guests that were staying at Shawe Road on the inspection have been to Shawe Rd before, but not for a number of years. They were therefore new to the present staff group. The information on one of these guests’ files was dated 2005. We were told that this information was from when the guest was previously at Shawe Road. Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 11 We would expect that additional (up to date) detail be provided by the local authority and also obtained by the manager before the guest arrives as the details within previous assessments could have changed. We were told that family had not wanted a visit to the guest’s own home to be arranged. We were also told and saw through looking at records that family had visited during the stay and had provided valuable information to staff to assist Shawe Road to know more about the guests. The AQAA indicated, “Before any guest is offered support we will take up any assessments, reports and care plans from the relevant people involved. (Regular meetings are in place with commissioners to decide on the appropriatness of referrals.) We then meet guests ,and their families give them information about the service (Guide to Service and the Welcome Pack ). We then agree a plan of introduction.This process also gives us the opportunity to complete our own Care Plan /Support Risk Assessment”. All staff were reported to have read guests’ file notes prior to their planned admission. The assessment process continues during guests’ stay at Shawe Road and these are revised as changing needs are identified. All guests were reported to have been sent a welcome pack, which included the statement of purpose so they or their families are clear about the service provided at Shawe Road. Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 &9 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Records were not always reflective of guests’ needs or support provision, which increases the risk of, needs being unmet. EVIDENCE: Shawe Road provides short stay care service, this influences the type of care, which is provided. Short-stay placements can be anything from overnight to couple of weeks or longer if this is arranged. On occasions unplanned placements are made to meet the needs of the relative or carer. From information recorded it is evident that guests are as far as possible consulted about their care needs and individual preferences. Some guests do not have full communication and for some their ability to understand their Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 13 surroundings is unclear. As a consequences family members make decisions on their behalf based on the knowledge they have of them. Direct observations identified that guests receive good support to maintain their health; however from inspection of their files it was evident that records required some development to ensure the care and support provided was recorded. One relative indicated that Shawe Road, “always” meets the needs of their relative. A relative said, “X looks forward to (their) stays at Shawe Road so I know that (they) must enjoy the time (they) spend there”. In response to the question what do you feel the care home does well, a relative responded, “They make X feel very welcome. Listen to what X would like to do or need. Care about the people they deal with”. All care plans and records should be up to date and reflect current practice. Care needs should be clearly identified, and included the strategies and interventions to meet needs. This was not always the case as care plans were not always within the care files looked at on this visit. We asked staff how they looked after guests and they responded that they would look at the care plan. One member of staff said, “There is a lot of info in care plans which I find useful”. Another member of staff said, “Most of the care plans have now been updated and completed”. There is for many of the guests a lot of information within the care files from many years ago. Some of the information is still relevant and gives staff and understanding into their lifestyle and abilities. However the amount of paperwork could be confusing to staff as the only care/support plans that were in some of the guests care files were from many years ago and guests needs had changed since this time. Daily recordings presented as being well maintained. Staff who were spoken to, said that the written records and the verbal information shared at each shift handover, helped them to be aware of the current care needs of each guest. Some of the guests take with them to the day centres their daily recording books so staff at the day centre also use the book to record what the guest has done whilst they were with them. This provides an overview of guests’ time inside and outside Shawe Road. A relative said that their cared for guest hadn’t attended Shawe Road, “ for some time now”. But felt that “There needs to be a better and consistent method of passing information on to parents like me whose (cared for guest) cannot communicate. It is impossible to find out exactly what X has done and where (they) have been during (there) stay at Shawe Road. I am always getting the answer, ‘I don’t know because I was not on duty this morning’ (yesterday, whenever)”. We were told by staff that a record is now sent home with guests giving this information to relatives or carers. Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 14 The AQAA indicated, “We have a system in place to make sure robust assessments and care plans are carried out in consultation with the guest, their family and the relevant professionals. These Care Plans are reviewed and adapted as guests needs change. We endeavour to treat the guests we support with respect, making sure we empower them to make decisions about the support they receive and how they wish to spend their time when staying at Shawe Rd. We work closely with guests and families in a very open and honest way which allows for issues to be raised and solutions found”. Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 &17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Guests are supported to live individual lifestyles, make decisions and be as independent as they can or wish to be. They are treated with dignity and respect and have opportunities to develop and acquire day-to-day living skills. EVIDENCE: Guests are promoted to continue with activity, as they would do at home. We were told that Shawe Road support guests to maintain their day time links e.g. day provision / employment while they stay at Shawe Rd. A number of guests attend day provision elsewhere which staff support and make the relevant arrangments. guests are supported to maintain their community links and activities during their stay. e.g. bowling, local pub, pictures and local Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 16 clubs. One member of staff said in response to the question what does the service do well responded, “the service is good at getting people out into the community. It is a happy place to work most days and there is a good consistent team”. Being a short break service there is regular involvment from families which is encouraged. Bookings are done to accomodate guests choices e.g. ‘themed weekends’.Some themes covered over past months have included a craft and a gardening weekend. We were told these were well attended. Individual care support plans did not always detail social routines and support provided to promote social involvement, hobbies or interests. We were told that staff have a relaxed approach to meals, in that guests chose what they would like each day on an individual basis from what is available within the home. This is more reflective of everyday life and enables guests to make choices and decisions for themselves about what they would like to eat. A record of food served has been developed since the last visit. The sample looked at identified that everyone on a particular day had the same meal. There didn’t appear to be a choice available. The team leader said staff do the weekly food shop and they know what each guest likes and dislikes so they buy these things. There was no record on the care files looked at of guests’ likes and dislikes with regard to food. Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 &20 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Medication procedures and recording are not sufficient to ensure practices are completely safe. EVIDENCE: Guests’ health care needs are detailed within the care file. This information is appropriate to the needs of guests and the support they need whilst staying at Shawe Road. The care plans need some development and the risk assessments need to be undertaken for all guests to safeguard them. Medication records (MAR), contained sample signatures and initials of those staff responsible for the administration of medication as is best practice. The medication administration records are handwritten; this is due to the short term service provided at Shawe Road. Best practice indicates that handwritten medication should be signed as being verified by a second member of staff to ensure the accuracy of the detail. Most of the medication records were signed and verified by two people, as is best practice. This practice is in place so staff Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 18 can make sure that the entries have been written correctly. It was of some surprise that a guest’s medication had not been copied correctly although verified by a second staff member. A staff member on duty had met the guest from a previous visit and remembered that they then had this medication twice a day and did some research to check this out. Had it been a member of staff who didn’t know the guest then this error might not have been identified. A record was made in the communication book to staff to say, “When completing med sheets please read the bottles correctly and transfer info into sheet there was an error with X”. It is Shawe Roads procedure that when staff administer medication that two staff sign the medication record to confirm administration. On this visit a member of staff was asked to be the secondary signature for medication administered earlier in the morning, which they hadn’t witnessed. They signed the medication record as they had been asked to. Staff need to be reminded of what they are signing for and not sign records without clearly understanding what and why they are signing. Another member of staff gave out liquid medication to two guests from the same bottle. This is not acceptable practice. Some of the medication records were not double signed in line with Shawe Roads medication procedure and there were some omissions in the recording of medication administration on 25th July 2008 for two guests. It could not be confirmed on that occasion that the medication had been administered. For another guest medication was recorded as prescribed twice a day and was recorded as administered. The second administration time was then crossed out. It was not clear if different instructions had been received or whether it was written down incorrectly or whether staff were signing the record without checking what they were signing. This record hadn’t been signed or verified by a second member of staff to confirm correct copying of the prescription. We were told that all staff who have the responsibility of administering medication have received training. The manager needs to undertake an assessment of staff competency levels in carrying out this task. Photographs to assist in the identification of guest’ were not on the medication administration records, as is best practice. This was a recommendation on the last inspection. The AQAA reported, “We encourage staff to monitor and report the effects of medication, to question why guests are on medication and to liaise regularly with health professionals and family members regarding medication”.We were told that in the next twelve months the manager intends, “Piloting administration of self medication assessment and further medication training”. Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 19 As reported on the last inspection the care support plan for each guest needs to clearly describe the ways in which guests perceive their needs and the expectations they have of the people supporting them. For example, the plan needs to detail preferred routines, personal care needs and emotional support requirements. There also needs to be a recognition that the type of support may need to change depending on the mental health and vulnerability of each guest at any particular time. Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 20 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 &23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Policies and systems are in place to support guests in making a complaint and to ensure they are protected from abuse. EVIDENCE: There is a clear and accessible complaints procedure in place, which outlines the timescales for dealing with a complaint and informs how complaints are dealt with. A complaints record is in place to record comments and issues raised. The AQAA indicated, “We work closely with guests and families in a very open and honest way, which allows for issues to be raised and solutions found”. One staff comment card when asked do you know what to do if a service user, relative or friend has concerns about the home responded, “Do my best to resolve any problems concerns and inform my line manager”. Another said, “Take details and pass it onto manager”. One guests’ comment card indicated that they knew how to make a complaint and another said, “only through mum and dad”. A further guest said they would speak to their advocate. The Commission for Social Care Inspection has not received any complaints about this service. Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 21 A number of staff had undertaken training in safeguarding Adults and staff who were spoken to during this visit were able to demonstrate an understanding of issues surrounding abuse. Some were aware that Social Services took the lead following an allegation of abuse and that the Commission for Social care Inspection (CSCI) had to be informed. It was reported that in induction staff cover this area of expertise. Staff need to attend the specialist training to ensure they are able to recognise signs of abuse and know what to do if abuse is alleged. The AQAA indicated that the manager intends in the next twelve months to, “Ensure all staff do the POVA training provided by the Local Authority”. We were also told that, Trafford’s safeguarding adults’ policy would be re launched this year and we will ensure that staff attend the training. We will invite Trafford to talk to relatives at one of our coffee morning’s”. There has been one safeguarding matter reported to the Commission. There was evidence that the manager was managing the incident well, that procedures were followed and the appropriate professional bodies were involved. Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 &30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The standard of cleanliness was good, providing guests with a clean place to stay. The redecoration has improved the appearance of the bedrooms and lounge. EVIDENCE: The building is owned by Trafford Council and the responsibility for its upkeep is with the council. The building available to IAS is part of a large bungalow and Trafford Council uses part of the remaining section as offices. IAS provides care to guests coming into Shawe Road and are using a building which does not belong to their organisation they are dependent on the local authority. We were told on the last inspection that the building was to be demolished. This is no longer the thinking of the council and it appears they are intending to upgrade the building. Timescales for this have not been provided to IAS. Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 23 The lounge and combined dining room have been redecorated since the last visit, which provides a much pleasanter and brighter atmosphere for guests. All guests’ bedroom have had new carpets fitted, which has improved the appearance of the room, and promotes guests’ dignity and self worth. The manager feels there is, “Still a long way to go to improve the quality of the environment, which will only really change with the redevelopment”. The AQAA indicated,”We have continued to commission additional cleaning services which have been contracted to enable more staff time to be spent with guests and maintain the standard of hygiene required. We recognise that the building is inappropriate to meet its purpose and is also in a poor condition. The plan is to redevelop the building at Shawe Rd. but in the meantime we have redecorated and fitted new window blinds and carpets where appropriate. The gardens need to be cleared and fences fixed etc. to make them more welcoming and safe. We are liaising with Trafford MBC who have responsibility for this”. A relative said, “It was (on X’s last visit) certainly time for a face lift. Everything was old and jaded”. Two guests indicated in their comment cards that Shawe Road was “always” fresh and clean and one guest responded “sometimes.” As reported on the last inspection, the kitchen and laundry is outside the designated area of the building, which means staff have to leave the “unit” to undertake laundry and cooking. The design of the kitchen and laundry are not as you would expect to see in a domestic dwelling and would not be what guests are used to. Shawe Road would need to undertake risk assessments if guests were to use these areas safely. The kitchen and laundry equipment is commercial in design and it is not envisaged that guests would be confident to use the equipment. This does not enable guests, if they are able, to continue to be independent and undertake practical tasks for themselves. We were told that if guests were used to using the microwave or toaster they could do this in the dining area where the staff make toast. Attention to detail was still lacking within some of the bedrooms, for example, curtains not hanging properly due to either insufficient curtain hooks or the curtain hooks not being fixed onto the curtain rail. This needs to be addressed by staff as a matter of routine. There is only one lounge area at Shawe Road, which is restrictive to guests as if they don’t want to be in the lounge their only alternative is to go to their bedroom. A member of staff in a comment card said, “The service could offer more choice for individuals e.g. separate room with different activities in them. Comfy chairs for people in wheelchairs to sit in. TV in more bedrooms”. Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 24 A relative made the comment that, ““There should be some system whereby residents are placed with others of a similar age. X is not at his happiest with 50 &60 year olds. There should be adolescent unit for those under the age of 30years”. Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Guests are supported by staff that have been appropriately recruited and selected, receive training and are supervised. EVIDENCE: The home employs seven full time staff and four part time staff. Two of the staff team have achieved National Vocational training at level 2 or above. Currently additional staff are completing NVQ training which when completed will mean that 50 of staff will have achieved NVQ qualification. This will then meet the required target set for such training. Employment files confirmed that the home follow recruitment and selection procedures. Prospective staff complete a job application form, which details their employment history and other relevant information. Statutory checks are completed and their attendance for interview. Records seen detailed the interview process and outcome. Job descriptions were in place as was person specification information relating to the position applied for. Letters of appointment were in place as was induction procedures, which met the standards set be skills for care. Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 26 Staff spoken to confirmed that the induction training was very detailed. However as staff have to wait for the five day training they can be working for a few months before they receive this training. This fact may compromise themselves and guests staying at Shawe Road. The manager needs to look at alternative ways for staff to receive for example, moving and handling training before they start this within their job role. The AQAA completed by the manager indicated, “Staff initially work alongside experienced staff. There is a thorough induction process and access to a range of training and development opportunities”. A member of staff indicated, “If I feel any training is needed that I haven’t done I know I contact my line manager who will then address the issue or concerns I have”. Another member of staff said, “Still having training and information is always available”. The AQAA indicated only a small percentage of staff have completed food hygiene training. Staff do whilst on duty prepare and cook meals for guests. To ensure staff are familiar with the rules and regulations in relation to food and preparation this training needs to be provided. First aiders were not identifiable on the duty roster; this needs to be arranged. The use of letters was used on the duty roster. If letters or symbols are used a definition of what they mean should also be included. The duty roster needs to detail the hours staff are working at Shawe Road. We were told that the hours allocated to Shawe Road are arranged to meet the needs of the guests accommodated and what the guests are doing during the day. A number of guests go to day centres, for example, during the day and return to Shawe Road before tea so not as many staff would be on duty at this time or if all guests were out for the day, the staffing would be arranged to accommodate this. Five staff members have left employment at Shawe Road within the previous twelve months. The age range of staff is varied, with those employed having differing backgrounds and work experiences. The manager described the staff team as committed, hard working and dedicated people who are supportive and loyal to the guests. Staff receive the codes of conduct set by the General Social Care Standards and are individually supervised and attend staff meetings. One guests comment cards in answer to the question do the carers listen and act on what you say said “always”, two said “sometimes” and one added, “If I speak up but I am a bit shy”. Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 27 Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 28 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 &42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The manager ensures the service is run in the best interests of the guests. EVIDENCE: Information in the AQAA states that policies and procedures have recently been updated and the manager said that this included fire procedures and checks. Jill Pilkington holds the post of Operations Manager with IAS (Services) Ltd, she has held this post since April 2003. Her duties and responsibilities include line managing team leaders, managing supported tenancies and setting up and developing the service at Shawe Road. Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 29 She is the registered manager at Shawe Road and obtained the registered managers award in 2005. Ms Pilkington does not hold a qualification in care. Ms Pilkington is aware that as the registered manager she is required to have an NVQ qualification in care and management and agreed to undertake this training as part of the registration. The registered manager does not work at Shawe Road full time as she has other commitments and roles within IAS. Two team leaders are in post one working twenty hours each week at Shawe Road and the second working twenty hours in a management capacity and twenty hours on hands on care. On the site visit there were no senior managers on duty. Support staff were on duty. Earlier in this report their were comments for example about the lack of a care support plans and risk assessments. The team leader was confident that there was one in place for one of the guests and obtained another copy. Staff had been providing support to the guest without this information readily available. Systems need to be in place to make sure that what managers think are in place are in place. Staff were also observed dealing with medication procedures inapproprately. It would assist in staffs’ development if senior staff were on site to support their develeopment and ensure that the records are up to date and procedures are followed. Senior managers have differing roles and are working on differing projects when not working at Shawe Road. There is we were told always a duty manager at the end of the phone who staff can ring for help or advise.The registered manager, team leader and health and safety manager made themselves available as part of this inspection. Information relating to fire protection indicated that the required weekly and monthly tests and checks were being carried out by staff employed at Shawe Road. Maintenance checks were undertaken to equipment at Shawe Road to ensure it works properly and is safe. Records to demonstrate these checks were made available on the visit to verify this. Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 30 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 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 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 31 No 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. Standard Regulation Requirement Timescale for action 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 YA6 Good Practice Recommendations Develop the care plans to include more detail of guests’ care needs and review and update risk assessments for all guests to promote their health, safety and wellbeing. A menu should detail all the mealtime options and alternative choices. All nutritional assessments need to be detailed to inform staff about likes and dislikes and the way foods should be served. A system needs to be put in place, which, wherever possible, enables guests to be consulted over meals. The recording in the menus needs to be in place to show to guests, wherever possible, what is on the menu. 3. YA17 Provide all staff who have the responsibility of preparing DS0000069192.V368981.R03.S.doc Version 5.2 Page 32 2. YA17 Shawe Road Short Break Service and cooking meals with basic food hygiene training and training in calorific and nutrition. This should ensure safe practice is followed. 4. YA20 A second signature must be in place to verify that handwritten medication has been copied correctly in the medication administration records, to ensure guests get the correct medication. To promote best practice and to aid in identification, a photograph of guests needs to be with their medication administration record. To ensure staff are familiar with the signs of symptoms of abuse arrange for all staff to attend specialist adult protection training. Ensure the duty roster indicates staff that are on duty whilst at Shawe Road and the actual hours of work are indicated on the duty roster. Maintain evidence that staff identification has been confirmed with all documents kept on staff files. Undertake training needs analysis for all staff and provide training to staff, which supports them to undertake their role and support guests needs. Provide CSCI with an action plan of all planned training for staff and the dates they are to attend the training. 10 YA37 Review the management arrangements at ensuring that staff are supported and developed in best practice by a manager that is in day to day control of Shawe Road 5. YA20 6. YA23 7. YA32 8. 9. YA34 YA35 Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Shawe Road Short Break Service DS0000069192.V368981.R03.S.doc Version 5.2 Page 34 - 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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