Inspection on 30/08/07 for Shawe Road Short Break Service

This inspection was carried out on 30th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shawe Road Short Break Service 29/07/08

Similar services:

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 09/07/2008.

CARE HOME ADULTS 18-65 Shawe Road Short Break Service 10 Shawe Road Flixton Manchester M41 5DL Lead Inspector Kath Oldham Unannounced Inspection 30th August 2007 8:20 Shawe Road Short Break Service DS0000069192.V335613.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 Shawe Road Short Break Service DS0000069192.V335613.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. Shawe Road Short Break Service DS0000069192.V335613.R01.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 747 6685 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.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.V335613.R01.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 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 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.V335613.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was unannounced, which means Shawe Road was not told we would be visiting, and took place on 30th August 2007, commencing at 8.20am. This was the first inspection at Shawe Road since the service was awarded to IAS Services Limited. Shawe Road provides short-term respite care for up to six people with learning difficulties. There are no permananent placements at Shawe Road. The inspection of Shawe Road included a look at all available information received by the Commission for Social Care Inspection (CSCI) about the service provided since the last inspection. 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, the views expressed in returned comment cards and those given directly to the inspector are included in this report. We got our information at the visit by observing care practices, talking with people staying at Shawe Road; talking with the manager 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 guests 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 guests. The care service provided to two guests was looked at in detail to help form an opinion of the quality of the care provided. 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. A brief explanation of the inspection process was provided to staff on duty at the beginning of the visit and time was spent at the end of the visit to provide verbal feedback to the manager. Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: There are many areas of development that Shawe Road can work on to further improve the service they provide to guests. These areas include the recording of and the checks in place in relation to medication. This will provide additional safeguards to guests and ensure errors are not made. The building is not in the best state of repair. However, IAS has identified areas that they are able to refurbish and this will make some difference to the appearance of the building. Some work has been undertaken by IAS to get rid of old equipment that seems to have been stored in guests’ rooms for a long time, but more sorting out is needed. The focus of IAS has been to meet the needs of the guests staying at Shawe Road and ensuring staff are employed having undertaken rigorous recruitment procedures to safeguard guests. The fire safety checks and staff attendance to fire drills and practice need to be put in place so staff are aware of what to do in an emergency. The fire safety checks are confirmation that all equipment is working which provides some safeguards for guests and staff. Although there are a number of recommendations, the home is, on the whole, providing an adequate service. The manager gave assurances that Shawe Road will continue to address the areas of development identified. Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 7 Some developments need to be put in place to detail guests’ likes and preferences in relation to food served to them and records kept of the meals they have eaten. This will ensure that if checks need to be made if guests are having nutritional meals, this can be demonstrated by the home. All staff need to have food hygiene training so they are aware of best practice in relation to the preparing and serving of food. 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.V335613.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 Shawe Road Short Break Service DS0000069192.V335613.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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Prospective guests have their needs assessed and are assured that the service is able to meet them. 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 their needs and aspirations are known by Shawe Road. As a way of getting to know the guests, IAS Services Limited sent a questionnaire to all guests or their relatives to get additional information to assist them to support guests and provide care as they need. The responses were not as IAS had envisaged, with the majority not being returned. IAS has appointed an additional team leader who is to commence full-time at Shawe Road in the week after the inspection to visit guests and their families to obtain this information. Time has been spent reading all the information on file to ensure staff are clear about the needs of guests on arrival and basic information is detailed on a board giving staff information at a glance. Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 10 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. The manager was very clear about the importance of having up to date information on all guests to ensure their stay is enjoyable and they receive the support and care they need. Prior to IAS taking over the staffing of Shawe Road, they spent three months shadowing Trafford Council Staff and the guests who were staying at Shawe Road at that time. 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.V335613.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 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The care planning and risk assessment documentation was not consistently sufficient to demonstrate care needs of guests EVIDENCE: Guests require differing degrees of support in aspects of daily living. This was clearly evident from observations of direct intervention and support provided by staff. The recording in the care plans did need some development to detail guests’ preferences and aspirations. Independence and increased life skills are promoted within a risk management framework. There were examples of guests being supported to participate in the community, to attend college or day centres, and to develop and maintain friendships. Some risk assessments were in place to ensure guests’ safety. Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 12 The service needs to record how it demonstrates it is responsive to each guest’s changing mental and physical needs and ability to self-care, which would help guests to maximise their choices and independence. The detail within the risk assessments also needs some development to ensure all risks are identified and action taken to minimise the risk. Guests said that they are encouraged to make decisions and exercise choice and to maintain and enhance their daily routines. They are able to discuss their choices with the manager and staff. Shawe Road provides short stay care service, this influences the type of care which is provided and care staff respond well to the arrival and departure of guests. All guests have been to Shawe Road before and are familiar with how it is run. Short-stay placements can be anything from overnight to a week’s stay. Due to this fact, the management at the home has planned to visit all guests scheduled to come into Shawe Road over forthcoming months. Guests’ privacy is maintained by staff knocking on doors before entering the room, by speaking quietly to guests and providing care and attention in bedrooms and bathrooms. Guests are not routinely given the opportunity to have a key to their bedroom door or somewhere in their room to lock items securely or privately. Shawe Road could amend practice to provide a key as a matter of routine and record if service users decline this offer or if they would be at risk from this. This would further enhance Shawe Road’s empowerment of guests to maintain their privacy. On the visit guests’ bedroom doors were open when vacated and anybody could walk into their room. Shawe Road Short Break Service DS0000069192.V335613.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. This judgement has been made using available evidence, including a visit to this service. Guests feel their lifestyle choices, expectations, and preferences in daily routines are respected and met. The development of the food served and the records of meals would demonstrate guests have a varied nutritional diet. EVIDENCE: Guests are promoted to continue with activity, as they would do at home. Activities are arranged routinely throughout the day and the week dependent on who is staying at Shawe Road and what they would like to do whilst there. When guests attend day centres or college, this continues and they are supported to attend whilst at Shawe Road. There is a clear emphasis on developing and maintaining social links with resources and public facilities which meet guests’ needs. Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 14 Staff support guests to access social and leisure interests inside and outside of the home. Individual care plans did not always detail social routines and support provided to promote social involvement, hobbies or interests. Staff take full responsibility for the preparation and serving of meals, including specialised diets. Whilst it was evident that some staff had completed basic food hygiene training, others had not. It was also not evident that staff had completed training in the preparation of nutritious and specialised diets. It was unclear if they had knowledge of calorific values of food and were aware of the methods used to promote better health through nutrition. Additional training should be provided to those staff with responsibility for the preparation of meals and specialised diets. There is currently no menu to detail the meals available to guests. It was reported that the menu changed to meet the needs of the guests at Shawe Road. There was no detail of meals served to guests, so it would not be possible to assess whether individual diets were satisfactory in relation to nutrition, for example. Shawe Road was unable to demonstrate that guests have meal choice. Two guests were at Shawe Road for lunch. Staff were unsure what they liked to eat and although the meal was said to have been enjoyed, staff did not know the preferences of guests. Shawe Road Short Break Service DS0000069192.V335613.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): 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 need further improvements to ensure practices are completely safe. EVIDENCE: All guests at the Shawe Road live within their own home and their independence is promoted whilst at Shawe Road for however long the period. Health appointments, which may have been made whilst they were at home, are supported and arrangements made for them to continue with their lifestyle as they would if they were at home. Guests’ health care needs are detailed within the care plan. 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. Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 16 The administration of medication is assessed on guests’ arrival at Shawe Road. If guests ordinarily self-medicate, then this would be supported. In practice, staff predominantly administer most guests’ medication. All the medication administration records are handwritten; this is due to the short tem 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. The medication records were not signed or verified by two people, as is best practice. This would make sure that the entries have been written correctly. The medication administration records for several people were examined and had not been completed properly in accordance with Shawe Road’s procedures. Medicines were stored correctly. There were occasions when the amount of medication was not booked in or out of Shawe Road, so it would not be possible to account for all the tablets brought in. The medication policy needs to be reviewed and refined to ensure that the policy is reflective of practice and staff are able to make reference to the policy if they need clarification. Best practice is to include specimen signatures and initials of staff competent and trained in giving out medication. This was not in place. One guest’s medication was not in a box or container supplied by the pharmacist, with the frequency of administration recorded on it. This could lead to misunderstandings and incorrect medication being given to guests. All medication received by the home must be in the original box or packet, with clear printed detail by the pharmacist of the medication and the amount to be administered. Photographs to assist in the identification of guest’ were not on the medication administration records, as is best practice. The care plan for each person 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 person at any particular time. Care plans include information about health care needs. Staff were observed to be reassuring and respectful towards guests, and to take the time to explain their actions, resulting in reduced anxiety for guests. Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Written complaints procedures ensure guests or their representatives have a means to raise views about the service they receive. Adult protection training needs to be arranged for all staff. EVIDENCE: All of the guests spoken with said that they would speak to someone at Shawe Road or with their family or friends if they had any concerns, and felt confident that action would be taken in response to their worries. There have been no complaints since registration. Guests were clearly comfortable approaching staff to ask questions or seek reassurance. Discussions and training records did not confirm that staff had attended training in adult protection and understand their role in protecting guests. Two staff were identified as having attended this training and 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. Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 18 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, 26, 28 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The lack of attention to detail and the appearance of the home does not promote guests’ dignity and individuality. EVIDENCE: The building is owned by Trafford Council and the responsibility for its upkeep is with the council. It is planned that the building be demolished in the near future and alternative accommodation built at some stage. The building available to IAS is part of a large bungalow and Trafford Council uses the remaining section. IAS has taken over the care of guests coming into Shawe Road and are using a building which does not belong to their organisation. Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 19 The manager said that they have removed a lot of stored items from bedrooms, as it was not safe and practicable to guests with so much spare furniture. The difficulties they have had is that the items do not belong to them and they had no knowledge of who they belong to. They have been reliant on the local authority to let them know, which hasn’t always been as quickly as they would like. There continues to be a need to remove items stored in guests’ bedrooms to promote their inviduiality and dignity, and to also ensure they have the space for their own belongings. One of the bedrooms contained two wash hand bowls. The sinks did not have plugs in place so the guest would not be able to use the wash hand basins to wash. Additionally, there were games, jigsaws, books, spare bedding and cushions, and also a specialist chair from a previous guest, in the room. Attention to detail was not evident within the rooms with, for example, curtains not hanging properly, bedroom doors were left open and the toilet seat in one toilet was stained with cleaning solution. The manager needs to carry out an audit of all rooms and remove the items to more appropriate storage and present rooms ready for guests. The lounge and combined dining room are to be redecorated, which will provide a pleasant and brighter atmosphere for guests. All guests’ bedrooms are to have new carpets fitted in forthcoming weeks, which will improve the appearance of the room and promote guests’ dignity and self worth. Guests do not have lockable storage in their rooms in which to keep items securely or privately. None of the guests had keys to their bedroom doors as a way or keeping their personal space private. This should be arranged, unless the guest would be at risk. This detail needs to be recorded within their care file. The house was clean and free from any unpleasant odours. Contract cleaners come into Shawe Road each day to vacuum and clean the house. 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. Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 20 The kitchen has been awaiting steam cleaning. IAS has now received the goahead to have this undertaken. This will improve the appearance and cleanliness of the kitchen. As described earlier, the arrangements are not permanent at Shawe Road and the support by IAS staff is for a period of nine months, when it is understood the service provided at Shawe Road will discontinue. Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Staff that have clear set roles and responsibilities that meet the needs of guests. Additional staff training would enhance the service provided. EVIDENCE: Staff said that relevant background checks were carried out before they were employed, and induction training was provided in the first few weeks of employment. Formal induction training is also arranged. Photographs of staff are seen as part of the recruitment process when IAS send for Criminal Record Bureau disclosures; but these need to be kept on file to comply with Regulations. On one staff file examined, this was not the case. Staff files were not held at Shawe Road, which needs to be arranged. They were made available on the visit. Staff records confirmed that suitable recruitment procedures are followed before staff commence employment. Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 22 On one staff file there was no detail to explain gaps in past employment or reasons for leaving, which are needed to safeguard guests and to comply with Regulations. Guests are not currently involved in the selection process; this could be arranged by, for example, guests completing a questionnaire after meeting prospective staff or having discussions afterwards. The questionnaire could, for example, ask for guests’ views about whether the candidate was polite and friendly, made them feel at ease or if guests would be happy to be supported by the person. Staff were reported to meet with their line manager regularly to discuss their practice, identify any training needs and to develop the service provided at Shawe Road. These records were not available on the visit to Shawe Road due to the line manager’s absence. This needs to be remedied and all records need to be available for inspection. The training provided to staff needs to be arranged in a timely manner to ensure staff have the skills they need to support guests. One member of staff, who was relatively new, was on duty on their own, supporting two guests in addition to preparing a meal for them. Additional training would support the staff to ensure they know what to do and how best to support guests. Examination of the duty roster identified the names of staff on duty. It did, however, detail a member of staff’s hours whilst working within another care setting. The detail suggested that the staff member was on duty at the home when they were not. 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. The manager said 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. Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. More rigorous management of health and safety practices are needed to ensure the safety of guests. EVIDENCE: The organisation ensures that Regulation 26 visits are completed each month, which means that someone from head office comes to Shawe Road and consults with guests and staff about service provision and standards, looks at records and discusses the running of the home with the manager. Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 24 The manager demonstrated a good level of knowledge and competence in her role. The manager spends two or three days at Shawe Road and a team leader manages the service day to day. An additional team leader has been appointed and has been working two days each week for the last month and takes up full-time employment at Shawe Road on the week after the inspection. This will support the management team and the service provided to guests. This should also ensure a senior person is on duty at all times. Policies and procedures are clearly written and discussed with staff during supervision sessions. Information relating to fire protection indicated that the required weekly and monthly tests and checks were not being carried out by the home. There appeared to be some misunderstanding, as IAS were informed that the Local authority was undertaking these checks, as they do for the remainder of the building which is on the same system. The manager said she would look into this immediately. Staff were not recorded as having taken part in fire drill practice and training. This is necessary to ensure they are aware of what to do in an emergency situation. On conclusion of the visit, the manager was asked to arrange for all staff on their next duty to attend fire drill practice and training and for staff to sign that they have received this training next to their printed name. Maintenance checks were undertaken to equipment in the home to ensure it works properly and is safe. For one hoist, the service history was not available. Information requested on the visit to confirm that the hoist had been serviced at the regularity required by health and safety guidelines had not been received by the Commission. On occasions, guests bring personal monies with them to enable them to purchase items or to pay for trips out. One guest had brought money with them on a previous short stay to Shawe Road and that money had remained at Shawe Road after the guest had returned to their own home. The balance correlated with the monies recorded. Best practice would be for any monies not spent during their stay to return home with the guest. This procedure needs to be put in place to safeguard guests’ monies. Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 2 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 2 35 2 36 3 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 2 X 3 3 X 1 X Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA42 Regulation 23 Requirement Arrange for the checks to the emergency lighting, means of escape, fire alarms and fire equipment to be undertaken at the regularity of the fire authority and a record maintained of these checks. Arrange for all staff on their next duty at Shawe Road to attend a fire practice and training to ensure they are clear about what to do in the event of an emergency situation. Timescale for action 30/08/07 Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA9 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. Carry out a risk assessment to enable guests to, where practicable and possible, have a key to their bedroom door to promote their privacy and dignity within their bedrooms and to keep their possessions safe and secure. A menu should detail all the mealtime options and alternative choices and a record needs to be maintained of actual meals served. 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. Provide all staff who have the responsibility of preparing and cooking meals with basic food hygiene training and training in calorific and nutrition. This should ensure safe practice is followed. 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 promote best practice, staff who are trained and are competent to administer medication should detail their usual signature and initials which should accompany the medication records. To safeguard guests and staff, ensure that a record is made of the number of tablets brought into the home and the number leaving the home on discharge is detailed on the medication administration records. 3 YA17 4 YA17 5 YA20 6 7 YA20 YA20 8 YA20 Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 9 Refer to Standard YA20 Good Practice Recommendations To safeguard guests and staff, ensure that medication brought into the home is in the original container or packet, which clearly indicates the time and frequency of medication administration. Review and refine the medication administration policy and procedure to ensure that it is reflective of practice and is available to staff so they know what they must do when taking charge of guests’ medication. Provide all staff who have the responsibility of administering medication with detailed medication training so they are aware of best practice and have a clear understanding of their responsibilities when administering medication. To ensure staff are familiar with the signs of symptoms of abuse arrange for all staff to attend specialist adult protection training. Undertake an audit of all rooms and remove all stored items and present the rooms available to guests taking into account individuals’ dignity, privacy and self worth. Provide guests with a lockable drawer or cupboard in which they can store items privately and securely within their bedroom. 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 all staff details and supervision and training, accessible for the purpose of regulation. Ensure that any gaps in employment are discussed with prospective employees and reasons for leaving past employment is explored and this detail is recorded on staff files. Maintain evidence that identification has been confirmed with all documents kept on staff files. Consider using guests in staff recruitment and selection to empower guests and take their feelings and views of prospective staff into account. 10 YA20 11 YA20 12 13 14 15 16 YA23 YA24 YA25 YA32 YA34 17 YA34 Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 18 Refer to Standard YA35 Good Practice Recommendations Undertake a 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. Ensure that all equipment used at the home has been regularly serviced as identified in health and safety guidelines to ensure it is working properly and is safe for use and a record of this is maintained at Shawe Road for examination. Ensure that monies belonging to guests are returned to them when they leave Shawe Road. Arrange for all staff on their receipt of fire drill training and practice to sign next to their printed name that they have received the training. 19 YA37 20 21 YA37 YA42 Shawe Road Short Break Service DS0000069192.V335613.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Greater Manchester Local Office 11th Floor, West Point 501 Chester Road Old Trafford 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.V335613.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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