Inspection on 15/05/07 for Shirebrook Fields Nursing Home

This inspection was carried out on 15th May 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Shirebrook Fields Nursing Home 11/05/08

Shirebrook Fields Nursing Home 17/05/06

Shirebrook Fields Nursing Home 21/09/05

Shirebrook Fields Nursing Home 22/04/05

Shirebrook Fields Nursing Home 13/01/05

Shirebrook Fields Nursing Home 05/09/04

Shirebrook Fields Nursing Home 16/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 Shirebrook Fields Nursing Home Spa Lane Woodhouse Sheffield South Yorkshire S13 7PG Lead Inspector Marina Warwicker Key Unannounced Inspection 15th May 2007 08:15 DS0000021807.V331911.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 DS0000021807.V331911.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. DS0000021807.V331911.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shirebrook Fields Nursing Home Address Spa Lane Woodhouse Sheffield South Yorkshire S13 7PG 0114 269 1144 0114 269 1133 sharonradford@shirebrookcaregroup.co.uk None Shirebrook Care Ltd 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) Mrs Sharon Radford Care Home 46 Category(ies) of Learning disability (46) registration, with number of places DS0000021807.V331911.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. The minimum staffing levels are agreed as proposed by Sharon Radford, Registered Manager, on 14th November 2005. This registration includes 10 nursing places at The Willows. This registration includes 6 nursing places at The Poplars. This registration includes 10 residential places at The Ferns. This registration includes 10 residential places at The Limes. This registration includes 10 respite places at The Acorns. One specific service user over the age of 65 years, named on variation dated 17/05/06, may reside at the home. 17th May 2006 Date of last inspection Brief Description of the Service: Shirebrook Fields is a care home providing residential and nursing care for up to forty-six people who have learning disabilities. The people who live at Shirebrook Fields have differing levels of learning and physical abilities. The home is divided into five units, two of which provide nursing care for up to sixteen service users. Three units provide personal care for up to thirty service users on a long term, short term and respite basis. The home is owned by Shirebrook Care Ltd. It is situated in the village of Woodhouse, Sheffield, and it is close to public transport and shops. The home is a single storey building, which includes a day centre. The home has individual garden areas for each unit and two car parks. Weekly fees for each person ranges between £800 and £1500. On top of this those who receive one to one support are given extra funding. DS0000021807.V331911.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was carried out on Tuesday 15th May 2007 between 8.15am and 5:15pm. Nine people who use the service were consulted and ten staff were interviewed. A further five service users, five relatives, five visiting professionals and five staff were contacted by post to obtain feedback about the service. Comments received from the surveys have been included in the body of the report. Time was spent observing and interacting with staff and the people who live at the home. The general manager and the care manager were present during the inspection. The premise was inspected which included bedrooms of the people and the communal areas inside and outdoors. During conversation with the management it was confirmed that additional charges are made for hairdressing, chiropody, daily papers, some activities, transport, some holidays and toiletries; further to the weekly charges. Care plans, medication records, service reports and staff recruitment and training files were some of the records checked. I would like to thank the people who live at the home, the staff and the management for their contribution to this inspection process. What the service does well: The people were assured by the management that the staff at the home were able to meet the needs of those who wish to move in. The people have had their needs assessed before moving into the home. Individuals were involved in making decisions about their lives, and play an active role in planning the care and support they wish to receive. This gives them the choice and support they need to maintain an independent life style. The people were encouraged to have a healthy diet by staff. The principles of respect, dignity and privacy were put into practice by the staff so that the people were able to live in a caring and comfortable setting. The home was kept clean and free of unpleasant smells. DS0000021807.V331911.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The following issues were identified and the service is expected to address these areas and make improvements so that the people receive a good quality of life at Shirebrook Fields. The reasons for needing such improvements are included below. The people living at the home and the visitors to the service need to have access to the home’s statement of purpose and the service user guide, which explains the running of the service and its aims and objectives. The information was not readily available or accessible. All the people living at the home did not have an accesssible contract or Terms & Conditions. The terms and conditions are in respect of the accommodation to be provided including the cost and method of payment. The agreement makes sure that both the provider of the service and the person using the service are aware their rights. The cooks and the kitchen assistants were not given peoples’ nutritional needs and their likes and dislikes in order for them to plan the menus. The staff did not sign the Medication Administration Sheets when they received medication from the pharmacist. Therefore there was no evidence of any checks made at the point of medicine delivery. The care staff need training in palliative care, practical assistance and bereavement counselling; so that they are competent in dealing with people growing older, terminal illnesses and end of life care. Not all care staff working at the home have had training in Protection Of Vulnerable Adults and deemed competent by the management. This training is DS0000021807.V331911.R01.S.doc Version 5.2 Page 7 essential so that people living and working at the home are protected from abuse, neglect and self-harm. Training needs analysis had not been carried out by the management and therefore the staff were not aware of any available opportunities to follow training in understanding Learning Difficulties and associated subjects. There was a lack of essential/mandatory training made available in the last 12 months i.e. moving & handling, health & safety, Infection control, First aid and Learning difficulty awareness. Therefore it is difficult to demonstrate that the staff have the skills and the competency to deliver the appropriate standard of care. Additional funding has been designated for special activities for individuals; the home was not maximising the use of the resources for those individuals. The progress of the home has been influenced by the following areas. The lack of information to those who use the service and the prospective users about the available services at the home, The lack of evidence whether the people and/or their representatives are aware of their Terms & Conditions of stay at the home, Not maximising the additional funding received for certain individuals who are living at the home and The lack of mandatory training for staff so that they are able to fulfil their duties to the people living at the home are some of the important areas the provider needs to focus on. 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. DS0000021807.V331911.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 DS0000021807.V331911.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): 1, 2, 3, 4 and 5. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The information for the prospective people who wish to use the service was not readily available so that they are able to make an informed decision. The people are assured that the staff at the home are able to meet the needs of those who wish to move in by the management. The people have their needs assessed before moving into the home. However, the Terms & Conditions/contracts are often not drawn up by the management, at the point of moving into the home. The contract tells the people about the service they will receive and also their rights. EVIDENCE: The people using the service and their relatives were consulted during the inspection process. The staff were interviewed and the documentation available at the home was checked. The evidence suggested that the statement of purpose and the service user guide were not readily available for the people and the visitors. The manager said that she was making amendments and that they were stored in the computer. She agreed to forward a copy to the DS0000021807.V331911.R01.S.doc Version 5.2 Page 10 Commission for Social Care Inspection and at the time of writing this report no information had been received. The three care files checked had care management assessments and also the home’s own assessment before the person was admitted to the home. The information was comprehensive and relevant. The home accepted emergency admissions; on the day of the site visit two people had been admitted as emergencies. The feedback from the surveys and the staff interviews confirmed that the people were offered trial visits to find out the suitability of the placement. Three contracts were identified for checking and only one was available on the day of the site visit. The manager said that one copy of the contract was at the head office and the other had not come through. DS0000021807.V331911.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 and 10. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Individuals are involved in making decisions about their lives, and play an active role in planning the care and support they wish to receive. This gives them the choice and support they need to maintain an independent life style. EVIDENCE: The three care plans checked had documentation, which had been agreed with the person receiving the support and their key workers. The care plans included identified treatment, risks associated with the placement, programme for rehabilitation. It also provides information on the facilities, which would be available for the person whilst living at the home. Some people had been fully involved in the planning of care and continue to report daily progress on themselves. DS0000021807.V331911.R01.S.doc Version 5.2 Page 12 Staff said that they were to move on to a Care Programme approach and were enthusiastic. But no progress has been made on Person Centred programme of care. During the day on several occasions it was observed that the care staff provided information and gave the people assistance to make their own decisions. During interviews the staff said that if decisions had been made by another professional they were always recorded and explained to the person by the key worker at the appropriate time. It was witnessed on the day that the people were supported to take risks and that the staff assessed the types of hazards and took measures to minimise the risks rather than stopping the person getting involved in activities. There was documentation on the care plans to support these actions. During staff interviews they said that when they receive information in confidence from the person using the service or their representatives they always respect their wishes and only in the best interest of the person would they share the information with others such as the managers. DS0000021807.V331911.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, 14, 15, 16 and 17. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. In the main the people who use the service are able to make choices about their lifestyle, and receive support to develop their life skills. On most occasions the staff arrange social, educational, cultural and recreational activities for the people so that they meet individual’s expectations. Most people are encouraged to have a healthy diet. EVIDENCE: The information from the people and the staff confirmed that the people were able to continue education and training and encouraged by their key workers to take part in valuable and fulfilling activities. On the day of the site visit people were seen going to colleges at different times of the day. Timetables of DS0000021807.V331911.R01.S.doc Version 5.2 Page 14 activities were seen in some bedrooms. One person proudly showed the inspector what activities s/he did during the week. During conversations with staff it was ascertained that the staff valued and respected the cultural and racial diversity of the people living and working at the home. They said that they helped those persons who wish to integrate into the local community by supporting them. The staff said, “We take clients out and if appropriate use public transport. Not all clients are able to tolerate being with people for long periods”. “Sometimes they go to the local shops by themselves”. The care managers had agreed to supply extra resources to meet certain individual’s aspirations and needs. These resources had not been maximised by the home. This was witnessed on the day of the site visit with regards to those people who were to receive one to one care. It was observed that people were able to choose whom they want to see in private. Family and friends were welcomed and the staff gave privacy. There were some people who had developed personal relationships with people of their choice. The staff were seen to offer the individuals help to make appropriate decisions. The staff addressed the people with respect and sought permission from them when entering their bedrooms. The staff also explained their actions and sought agreement from the people before carrying out any care. The staff said that the administrator delivered the individuals’ mail to the unit. The senior staff then distributed the mail to the individuals and if anyone needed help with reading the ‘seniors’ read them to the people. The people living at the home and the staff said that choices of meals were offered at meal times. The people were supported to have their meals and the times of meals were flexible to suit individual needs. The site visit took place during breakfast and lunchtime and it was noted that people were able to have their meals in a relaxed manner and staff were available to help them. The cook had a basic food hygiene certificate and the assistant cook had attended similar training. However, it is good practice for the cook to be trained to Intermediate food hygiene standards and the others handling food to be trained to the basic level at least. During conversation with the cook and the manager it was ascertained that the kitchen was not staffed adequately. There was not enough involvement between the people living at the home, the care staff and the cooks. There was no information for the kitchen staff on the special diets the people were on and their likes and dislikes with regards to food. The lack of such information makes it impossible for the kitchen staff when ordering food products and planning menus. The kitchen looked in need of renovation and refurbishment. The manager assured me that it was to be carried out this year. DS0000021807.V331911.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 and 21. People who use this service experience good, quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The health and personal care of those people who live at the home is based on their individual needs. The principles of respect, dignity and privacy are put into practice by the staff so that the people are able to live in a caring and comfortable setting. EVIDENCE: Direct observations on the day and the feedback from people who use the service and their relatives, confirmed that the staff offered personal support in private and intimate care by the same gender staff as far as it was practicable. Times for getting up and going to bed were flexible. The key workers assisted those people who need help to keep appointments and to go to places such as colleges and day centres. All the people seen looked relaxed and comfortable. Their appearance and what they did each day reflected the diverse personalities of those who lived at the home. The staff nurtured the individuals to develop their personal traits. DS0000021807.V331911.R01.S.doc Version 5.2 Page 16 The manager said that all those who live at Shirebrook Fields have access to the community health care team and the staff were in regular contact. Some people were capable of asking to see the health care professionals and the key workers identified this and made the necessary arrangements. On the day of the site visit, there was no one deemed by the staff as having the capacity to self medicate. Records were kept of the medicines administered and disposed of. However, none of the three Medication Administration Sheets checked had records of medication received by the staff on behalf of each person residing at Shirebrook fields. The manager was informed of this. The last pharmacy visit was in May 2006. Since there has been a change in the contractual agreements between the community pharmacists and the PCTs Primary Care Teams- the pharmacy audit only takes place if the home requests. However, it was evident that the manager sought information and advice from the pharmacist. There were three large containers waiting to be disposed of by the home. In the residential care units there were designated staff who were trained and were allowed to handle medication. Discussions took place with senior staff with regards to introducing a system for all staff being able to identify the reason for medication and recognised side effects. The management assured the people who live at the home, that they were able to remain in the home when they grow older. This was evident during the site visit. During staff interviews and via consultation with other professionals it was understood that the staff were able to identify the changing needs (e.g. when people develop deteriorating conditions) of the people and provide appropriate personal support and technical aids to make them pain free and comfortable at the end of life. However, it was identified by the staff that the people living at the home were not receptive to discussing death and dying. They identified the need for formal training for all staff in palliative care / end of life care and bereavement support for people within the home community and also for the staff. During discussions the staff said, “We become very close to the residents and sometimes feel helpless to support the families.” “It will be a good idea to get some proper training rather than learning on the job.” “ For one of our residents this training is too late. We were devastated when it happened and I did not feel that we had access to any counselling.” The manager was made aware of this. DS0000021807.V331911.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 and 23. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Most of the people who use the service are able to express their concerns and know that the staff listen to them. The people and their representatives have access to a complaints procedure. The people are protected from abuse, and they have their rights protected by the home’s policies and procedures. EVIDENCE: There was a record of all the formal complaints maintained by the manager. There had been three complaints since the last inspection report and the documentation stated that these had been handled within the timescale to the satisfaction of the complainant. The staff interviewed said that they had read the procedure and were able to verbalise the content. It was ascertained during the site visit and also through feedback and the records that the manager and the staff took all practical measures to safeguard people who use the service from abuse, neglect, discrimination, self-harm and degrading treatment. Staff said, “Before I started work here I had to wait for a CRB clearance and satisfactory references.” Not all staff employed had received formal training in Protection Of Vulnerable Adults. This training needs to be compulsory as part of induction. DS0000021807.V331911.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, 29 and 30. People who use this service experience good, quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. The present layout of the home maximises the ethos and the aims of the service. In the main the home is kept clean and free of unpleasant smells. EVIDENCE: On the day of the site visit it was noted that the premise had been made suitable for its purpose. The tour of the premise was carried out with the manager who updated me with the plans for continuing refurbishment. All areas were accessible, safe and well maintained. The efforts made by the management to improve the building structure, the maintenance of the DS0000021807.V331911.R01.S.doc Version 5.2 Page 19 property and refurbishment has provided the people who live at Shirebrook Fields with a comfortable and a homely environment. There were ample shared spaces in each unit. There were enclosed safe outdoor spaces for the people to enjoy. All bedrooms were single with ensuites. Most rooms were able to accommodate wheelchair users. Three people showed their bedrooms and showed their pictures and belongings. They were very proud of their rooms and also to have someone to see their rooms. The rooms were lockable and they were personalised with the individuals’ belongings. The staff on duty and the manager said that they had adequate moving & handling equipment and aids. Although the home is on one level there were internal ramps and stairs to allow access between the different units. On the day of the site visit the units were clean, hygienic and free from offensive odours. The staff were able to discuss the measures they took to control the spread of infection. Although the laundry facilities were sited next to the main kitchen, the present arrangement separates the two areas by a corridor. The laundry staff said that there were adequate people to support the laundry most of the time. In some units there were washing machines to facilitate people with their independent living skills. DS0000021807.V331911.R01.S.doc Version 5.2 Page 20 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, 35 and 36. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. On the whole the staff employed at the home are trained, skilled and in sufficient numbers to support the people who use the service. However, the staffing levels are not maintained in line with the Terms & Conditions agreed by the placing authority. The management have a commitment to staff recruitment, training and development, which needs to continue so that each person is able to receive the appropriate funded care. EVIDENCE: Four staff training files were randomly selected. Ten staff were interviewed and feedback from the surveys were also taken into consideration. The staff team were efficient, effective and took pride in what they did. The surveys confirmed that the staff team reflected the culture and gender of the people who live at the home. DS0000021807.V331911.R01.S.doc Version 5.2 Page 21 The ratios of care staff were determined according to the needs of people who use the service. However, those who were funded to have 1:1 care for a set number of hours did not always get this. The manager said that this was due to the reluctance of staff and also the lack of opportunities for the people. The manager said that all care staff were over 18years of age. Regular staff meetings had taken place and there were minutes of these meeting made available for the inspection. Four staff recruitment files were checked and staff were interviewed with regards to their recruitment. Most information required by the Care Home Regulation 2002, Regulation 19. ‘Fitness of workers’ was available. However, the following gaps were identified and the manager tried to rectify these during the day. • Not all staff application forms had records of full employment history with explanation for the gaps in them. • Two staff did not have signed and dated contract of employment at the time of check. The staff and the manager identified Training and Development as a continuing process. However, the management need to reward the commitment and enthusiasm of the staff working at the home by facilitating the necessary training. During staff surveys it was evident that the staff were interested in formal training in learning disability awareness, training in different methods of communication and opportunities to network with those who are involved in this specialist area. Although progress has been made on enrolling staff on NVQ awards; there needs to be a concerted effort made for staff to receive training in understanding Learning Difficulties and associated subjects. Four staff training files were checked. All four staff have had fire safety training in the last 12 months. One staff has had training in Nutrition awareness, Another two have had training on Protection Of Vulnerable Adults And further two have had training in physical interventions. None of them had evidence/ certificate/ dates to establish that they have had the following training. 1. Moving & handling 2. Health & safety 3. Infection control 4. Tissue Viability 5. Continence care 6. Medication management training for the care staff 7. First Aid DS0000021807.V331911.R01.S.doc Version 5.2 Page 22 8. Learning Difficulties awareness The manager was unable to verify this on the day of the site visit since the training information was with another staff. During interviews the staff were unable to confirm whether they had received the above training. These were some comment made by staff. “Did not have any formal induction. Just followed the staff and they taught me”. “On the first day I was showed around the unit I will be working in and then deputy manager told me where the fire points were and discussed with me about some of the residents I needed to know before going on the unit.” “I love working with people with learning and physical difficulties. I know I like caring but this is more of friendship. I am keen & observant. This is what helps me enjoy my job.” The manager and her deputy had an example of Induction, which the staff received. However this programme needed to be in line with the Skills for Care induction package. Discussion took place between the manager and the inspector with regards to all staff, including those who had been employed in the last three years receiving the updated version of induction and deemed competent. A way of implementing this training is to include this in the into staff supervision targets. One of the comments from the survey was, ”The staff are able to deal with short term and emergency situations. But the staff are unable to deliver individual’s health care since they are unsure and will benefit by suitable training”. All staff interviewed said that they were fully supported and supervised by the manager, deputy and the senior staff on each unit. The four staff files checked, all four staff had formal recorded supervisions. DS0000021807.V331911.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 and 42. People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The management and administration of the home is based on openness and respect for those who use the service. The home did not have a comprehensive quality auditing system. The registered manager as far as it is practicable has systems in place to safeguard the health and wellbeing of the people who live and work at the home. DS0000021807.V331911.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager is a qualified and experienced person to run the home. The management were still in the process of developing quality assurance systems, which were to be used by the staff to monitor the standard of care they delivered. Monthly reports from the Responsible Individual were not available. The manager said that the registered provider was to carry out the yearly audits to seek the service users’ satisfaction of the package they receive. The outcome of this survey was to be shared at all levels. This has not happened hence there was no feedback available for inspection. The pre-inspection record indicated that the necessary risk assessments had been carried out and the equipments checks had been maintained. During staff interviews they were aware of the need for reporting of incidents such as outbreak of illnesses, all accidents, any deaths, and any allegations of abuse at the home to the managers. The manager said that she was in the process of reviewing all the home’s policies. DS0000021807.V331911.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 2 2 3 3 X 4 3 5 2 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 3 25 3 26 3 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 X 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 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 2 3 X 2 X X 3 X DS0000021807.V331911.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA35 Regulation 18 Requirement Timescale for action 16/07/07 2. YA6 13 3. YA39 24 All care staff must be offered the opportunity to complete the LDAF induction and foundation training. (Previous time scales 16/6/04, 31/12/05 and 01/12/06 not met). The staff training to address the above requirement must be available by the given date. Care plans must be further 28/08/07 developed in line with a person centred planning approach. Previous time scale:01/12/06. The manager must adhere to the stated timescales: 30 by 28/08/07, 60 by 30/10/07 and completion i.e. 100 by 21/12/07 The manager must keep a record of the names of the peoples’ files, which had been updated. An effective quality audit system 15/08/07 must be developed and maintained. The management must seek the views of the people living at the home, their relatives and the visiting professionals to the DS0000021807.V331911.R01.S.doc Version 5.2 Page 27 4. YA39 24 5. YA1 4&5 6. YA5 5 7. YA17 12,16 service. (Previous timescale 16/6/04 31/3/06 and 01/07/06 not met). The manager must have evidence that people using the service had been contacted to seek their opinion of the service provided by the date set. The responsible individual must carry out an unannounced visit each month to monitor the conduct of the home. A report must be completed and must be available for inspection on request. A copy of the report by the Responsible Individual for the month of June 2007 must be forwarded to the local Commission for Social Care Inspection office by the stated date. The people living at the home and the visitors to the service must have access to the statement of purpose and the service user guide at all times. The information must be readily available and accessible so that informed decisions could be made. All the people living at the home must have a contract or Terms & Conditions. The terms and conditions is in respect of accommodation to be provided including the cost and method of payment. This must be agreed and signed by the individuals or their representatives and the provider of the service. This agreement makes sure that both the provider of the service and the person using the service are aware their rights. The cooks and the kitchen assistants must be appropriately DS0000021807.V331911.R01.S.doc 10/07/07 10/07/07 24/07/07 15/08/07 Version 5.2 Page 28 8. YA17 12 9. YA20 12,13 10. YA21 12,18 11. YA23 18 12. YA32 18 trained in nutrition and food hygiene so that the people receive a healthy and balanced diet. The staff training must be organised and dates be available by the given time scale. The cooks and the kitchen assistants must be aware of the peoples’ nutritional needs and their likes and dislikes in order for them to plan the meals /menus. The staff must keep records of all medication received by them. The records must include the dates and the amount of medication received together with their signatures. The care staff must be trained in palliative care, practical assistance and bereavement counselling; so that they are competent in dealing with people growing older, terminal illnesses and end of life care. The training dates and arrangements made must be available by the stated time scale. All care staff working at the home must have had training in Protection Of Vulnerable Adults and deemed competent by the management. So that people living and working at the home are protected from abuse, neglect and self-harm. Dates of staff training arrangements for POVA must be available at the home by the given date. All staff working at the home must have had mandatory training in the last 12 months. The subjects include, moving & handling, health & safety, Infection control, First aid and Learning difficulty awareness. DS0000021807.V331911.R01.S.doc 16/07/07 10/07/07 15/08/07 15/08/07 15/08/07 Version 5.2 Page 29 13. YA33 17,18 Dates of staff training arranged to comply with the above must be available at the home by the set date. The staffing levels must be determined according to the assessed needs of the people. Where additional funding has been designated for special activities for individuals; the home must ensure that it is achieved and the funding authorities must be kept aware of progress. 10/07/07 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 YA20 YA34 Good Practice Recommendations An integral part of medication management is the disposal of unwanted medication and the containers. The management should better manage this. The staff recruitment with regards to the gap in service should be explored and all the employees should have a contract, which has been agreed and signed by both parties. Training needs analysis should be carried out by the management and all staff should be given the opportunity to follow training on understanding Learning Difficulties and associated subjects. 3. YA35 DS0000021807.V331911.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000021807.V331911.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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