Inspection on 19/12/06 for Short Break Services

This inspection was carried out on 19th December 2006.

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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Short Break Services 25/04/06

Short Break Services 22/12/05

Short Break Services 18/05/05

Short Break Services 14/12/04

Short Break Services 03/06/04

Short Break Services 23/12/03

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Short Break Services 62 Green Lane Hanwell London W7 2PB Lead Inspector Robert Bond Key Unannounced Inspection 19th December 2006 1:30 Short Break Services DS0000032384.V319787.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 Short Break Services DS0000032384.V319787.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. Short Break Services DS0000032384.V319787.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Short Break Services Address 62 Green Lane Hanwell London W7 2PB 020 8579 9558 020 8579 9592 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) London Borough of Ealing Mr Christopher Jones Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Short Break Services DS0000032384.V319787.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th April 2006 Brief Description of the Service: Short Break Service is a respite provision for adults with Learning Disabilities, some of whom have profound physical disabilities also. There are three aspects to the service, namely flexible day, evening or overnight respite care within the unit, off-site weekend day time respite care at the Cowgate Centre, Greenford, and an outreach respite service during the summer for 19 to 24 year olds whereby service users are collected from their parents’ homes and taken for activities. The only part of the overall service that is covered by the Care Home Regulations, and hence CSCI inspections, is the over-night stays within the Green Lane building. This aspect of the service is part of a resource centre, which is owned and managed by the London Borough of Ealing. This building at 62 Green Lane, Hanwell, can accommodate up to six service users on the ground floor who have complex needs, and four service users on the first floor who are ambulant. The first floor bedrooms do not meet the minimum size requirements for bedrooms. Facilities include a sensory room, a computer room, adapted bathing and showering facilities on the ground floor and an enclosed rear garden. Short Break Service is situated in a cul de sac area and set back from the main road. The service is within reach of Ealing Hospital, local amenities, recreational facilities and public transport links. Short Break Services DS0000032384.V319787.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspector spent four hours on site during which time he interviewed the Registered Manager, met other staff members, observed care being provided to several service users, and examined a range of records. The inspection took place during the afternoon, as all the staff group were undertaking Food Hygiene training on site that morning. In advance of the inspection, the CSCI sent out questionnaires to service users, their relatives, professionals connected with the home, and to the Registered Manager of the home. Twenty responses were received, 19 of which were very positive. During this ‘key’ inspection, the Inspector assessed the performance of the service against the key National Minimum Standards (NMS) within the Department of Health’s Standards and Regulations for Care Homes for Younger Adults. The Inspector found that 15 of the anticipated outcome were fully met, whereas 6 anticipated outcomes were only partially met, and 2 were not met. However one anticipated outcome was exceeded. The Inspector made 14 requirements and 3 recommendations in total. In terms of equality and diversity, over 50 of the service users are from black and ethnic communities. Particular attention is paid when undertaking assessments and drawing up care plans to cultural needs such as diet and gender to gender care. At the request of some Muslim families, an all female service is sometimes offered. Overall, progress has been made in meeting the NMS, and the number of requirements made in this inspection report is slightly lower than in the previous CSCI report (17 reduced to 15 requirements). Care planning in particular has improved. The main concerns remaining are about the premises, their furnishing and their equipping (especially the hot water supply), particularly as some of the shortfalls have health and safety implications. What the service does well: The service provides a very good respite care service to adults with learning disabilities and associated physical disabilities. The service is greatly beneficial to service users and parents alike. At the present time approximately 56 service users and their families are using the service. As mentioned in the brief description of the service (above), the service is extremely flexible, and varied. A revised and improved care plan format has been introduced and is now used in most instances. Thus care is being provided in line with identified care needs. Short Break Services DS0000032384.V319787.R01.S.doc Version 5.2 Page 6 Most of the care home has been redecorated and is reasonably furnished. Staff, service users, and relatives are consulted very well, and relatives views in particular do affect the type of service offered. What has improved since the last inspection? What they could do better: Each service user’s family must be sent a letter, contract, or statement of terms and conditions that adequately describes the services that are to be offered or provided following the assessment of needs of the service user and the family prior to the service commencing. Each version of the care plan should be signed where possible by the service user, their representative, or a member of their family, to demonstrate that appropriate consultation has taken place and agreement reached concerning the content of the care plan. The daily record of activities undertaken within the care home aspect of the service, or organised by the service, must be completed each day. The service must keep on every care file a photograph of the service user. The downstairs bedrooms must be adequately maintained in terms of curtains, walls, lighting, and radiator guards. The downstairs bedrooms must be adequately furnished with wardrobes as the current ones are mostly damaged. Short Break Services DS0000032384.V319787.R01.S.doc Version 5.2 Page 7 It is recommended that two additional hydraulic beds, and a new shower table are purchased. All hot water pipes that create a potential hazard for service users must be boxed in. The lighting in the first floor corridor must be improved. The refrigerator on the first floor must be defrosted, or taken out of service completely. Hot water at the correct safe temperature must be provided for service users use in all areas of the premises. Temporary agency staff used by the service must be adequately trained during an induction process when first working for the Shortbreaks service, and the service’s records must demonstrate that adequate training has taken place. Permanent domestic staff working for the service must have their training needs formally identified, and met in a structured way. The temperatures of hot water throughout the building must be taken and recorded on a more regular basis. When the remedial work on the hot water system has been completed, the CSCI requires a satisfactory Legionella testing certificate and evidence that the premises as a whole are now compliant with the Water Supply (Water Fittings) Regulations, 1999. To cover the period whilst some hot water temperatures remain too low or too high in parts of the building, a documented risk management process is required to ensure that the risks to service users and to staff in relation to infection control and to scalding are minimised. 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. Short Break Services DS0000032384.V319787.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 Short Break Services DS0000032384.V319787.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): 3 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although good assessments are undertaken before the service commences, no formal mechanism is in place to adequately notify the service user and their family of exactly what service is being offered as no letter or statement of terms and conditions is prepared. EVIDENCE: The Inspector selected at random the records of one service user to be examined in detail, that is, ‘case-tracked’. The Inspector found that an appropriate assessment had been undertaken prior to the service commencing, by the ‘community team’. A good care plan had been developed that was based on that assessment. The Inspector requested the Registered Manager to show him a copy of the letter or contract sent to the service user’s family following the assessment in which details of the service to be offered or provided are given. The Registered Manager responded that letters, contracts or statements of individual terms and conditions were not issued. NMS 5 says that each service user must have an individual contract or statement of terms and conditions relating to their stay within the care home. Regulation 5 says ‘where a local authority has made arrangements for the provision of accommodation or personal care to the service user in a care home, the registered person shall supply to the service Short Break Services DS0000032384.V319787.R01.S.doc Version 5.2 Page 10 user a copy of the agreement specifying the arrangements made.’ See Requirement 1. Short Break Services DS0000032384.V319787.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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans are very good, but in order to evidence that service users and their families know their assessed and changing needs are correctly reflected in those care plans, the obtaining of signatures is recommended. Service users are well empowered to make their own decisions. Service users are well supported to take risks as part of an independent lifestyle subject to the constraint that that as this is a respite service, the wishes of the family are also taken into account. EVIDENCE: The Inspector found a good care plan upon the care file that he ‘case-tracked’. The care plan had been updated in March 2006. The care plan had not however been signed by the service user, or a member of the service user’s family. Such a practice is recommended as it provides evidence that they have been involved in drawing up the care plan and consulted about any changes subsequently made, as required by NMS 6.10 and Regulation 15(1). See Recommendation 1. Short Break Services DS0000032384.V319787.R01.S.doc Version 5.2 Page 12 The Registered Manager reported that care plans now follow the new improved format, and are reviewed annually, often in conjunction with the care plans used in day services that most service users also make use of. The Registered Manager added that some service users have communication passports, and multi-media profiles. The Inspector was shown a video example of a profile that had been prepared in a person-centred planning way. The daily notes the Inspector read as part of the ‘case-tracking’ were good. The Registered Manager confirmed that service users are involved daily in deciding what activities they wish to engage in, and what they wish to eat. Formal consultation forums exist, and the service now has a peer advocate provided by Ealing Mencap. The Inspector noted a poster in the foyer of the building concerning this new advocacy provision. Although formal risk assessments are not undertaken, the elements of risk analysis are built into the revised care plans in the form of very detailed instructions on how to provide personal care in an individualised way. The Inspector confirmed this from the care file he ‘case-tracked’. Short Break Services DS0000032384.V319787.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities for social development, learning and activities are provided and maintained in a satisfactory manner. Attendance at day centres and other activities are encouraged well. The recording of activities provided within ‘the service’ is not yet sufficiently robust. Service users are provided with a diet that is sufficiently healthy and has plenty of choice options. EVIDENCE: The Registered Manager reported that none of the service users had any paid employment but that many attend day centres and adult education and hence service users’ respite usage was fitted around their day centre and college attendance. Short Break Services DS0000032384.V319787.R01.S.doc Version 5.2 Page 14 All the service users live in the community with their parents. Family relationships are maintained during the respite periods. Several of the questionnaires that the Inspector received back from families contained glowing testaments praising all aspects of the service received. The Registered Manager reported that service users are offered a key to their bedroom when appropriate and are referred to by the name of their choice. The Inspector confirmed this from the file examined. Service users are not expected to assist with cooking or cleaning their bedrooms, although some do choose to. Service users are taken out by staff in the Service’s own vehicle, and visits are made to social clubs and the cinema. The service has a sensory room and a range of games, music, television, video and play station. A record is kept of activities undertaken by each service user. The standard of the record has improved since the last inspection, but the associated requirement is restated in this inspection report as gaps in the activity record remain, to the extent of 4 blank days within a two month period. See Requirement 2. The same issue has been reported in a Regulation 26 report dated 28th Nov. 2006 where the author writes, ’staff must be encouraged to ensure an accurate audit of all activities is maintained. Data should be used to plan future activities.’ The Inspector examined the home’s menu, samples of which were provided to him in advance along with the pre-inspection questionnaire. The Inspector noted that three choices of food are usually available, food is liquidised as necessary and PEG feeding can be done. The standard of the record that is kept of who eats what, has improved. Short Break Services DS0000032384.V319787.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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users do receive personal support in the way they prefer and require as the care plans are excellent in this respect. Each care plan file however must contain a photograph of the service user. Service users’ physical and emotional health needs are well met. Service users are adequately protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: The Inspector examined in detail the care plan of one service user chosen at random. The personal care goals and how staff should meet them were described extremely well. What was missing however was a photograph of the service user. See Requirement 3. A second care file was examined to ascertain whether the use of specialised equipment was adequately covered in the care plans. The second care file contained risk management aspects relating to the hoisting that was necessary for that service user. Short Break Services DS0000032384.V319787.R01.S.doc Version 5.2 Page 16 In terms of health care, the front sheet of each care file provides a summary including contact details for the service user’s GP. The Registered Manager reported that health needs are generally met via the family unit, as this is a short-term respite service. Nursing care is not normally provided but service users’ health is monitored and weight is recorded where required. Specialist health services that service users require are generally accessed via their day centre attendance. The Inspector examined a sample of medication records and identified no errors or concern issues. The list of staff signatures of those who are trained to give medication was been updated. Short Break Services DS0000032384.V319787.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives can feel that their views are adequately listened to and acted on. Service users are adequately protected from abuse, neglect and self-harm. EVIDENCE: The Inspector examined the home’s complaints record, which was found to be satisfactory. One complaint had been recorded since the previous CSCI inspection. No complaints about the service have been brought to the attention of the CSCI. The Inspector examined training records that indicated that all permanent staff members have been trained in the Protection of Vulnerable Adults. Short Break Services DS0000032384.V319787.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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users stay overnight in premises that are insufficiently homely and safe due to inadequacies in the furnishings and hot water supply in particular. The premises are sufficiently clean and hygienic, except for the first floor refrigerator. EVIDENCE: The Inspector toured the premises in the company of the Registered Manager. The Inspector found that the first floor bedrooms were small, being according to the figures the Registered Manager provided, 6.28, 6.31, 6.41 and 7.42 square metres respectively. The implication of such small rooms is that there is not sufficient space to provide all the items of furniture that the NMS specify. The Registered Manager argued the case that no-one stayed in the smaller bedrooms on the first floor for more than a week at a time, and therefore a smaller room size and a lower level of furnishing is more tolerable than it would be in a long-stay care home. Short Break Services DS0000032384.V319787.R01.S.doc Version 5.2 Page 19 The Inspector also found some of the larger downstairs bedrooms to be in need of additional provision. For example, room number 6 lacked a pair of curtains and had a poor level of lighting, room number 1 did not have a radiator guard, and room number 2 displayed a hole in the plaster of the wall. See Requirement 4. The Inspector found that most if not all the free-standing wardrobes in the downstairs bedrooms were damaged, and hence must be replaced. Requirement 5. Bedroom 1 now has a hydraulic bed installed in it. It is recommended that two more similar beds are purchased in order to assist the support staff in meeting the profound needs of service users who use the downstairs bedrooms. Recommendation 2. The Inspector found hot water mixer valves and pipe-work in Bedroom 1 and in Bathroom 2 was not boxed in thereby creating a potential hazard for service users. Requirement 6. The first floor corridor is overly dark due to the presence of lamp shades that must be cleaned or replaced. Requirement 7. The refrigerator in the first floor kitchen was found to be in need of defrosting. The Registered Manager said the fridge was not in use, but it was seen to contain some food and drink items. It must either be made fit for use or taken out of service completely. Requirement 8. The shower table in Bathroom 1 was observed to be worn and damaged. Its replacement is recommended. Recommendation 3. On a positive note, the Inspector noted that some redecoration of bedrooms in particular had taken place, bedside table lamps had been made available, and some additional bedroom furniture had been provided in the downstairs bedrooms, where space allowed. However as the Registered Manager reported, the premises hot water system had not yet been fully brought up to standard. As a result hot water in some parts of the building is never hot enough, whilst in other parts it is always too hot. The Registered Manager added that the work to correct the water pressure and hence its temperature is due to be finished by 1st April 2007. In the meantime the requirement concerning hot water remains. In addition, until the necessary remedial work is complete, the home must have a satisfactory documented risk management process in place to ensure that risks to service users and staff relating to infection control, and the danger of scalding, are minimised. See Requirements 9 and 15. Short Break Services DS0000032384.V319787.R01.S.doc Version 5.2 Page 20 The Inspector found the premises to be adequately clean and hygienic throughout, except for the first floor refrigerator. Short Break Services DS0000032384.V319787.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): 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient staff are rostered to work and the permanent support staff are competent and adequately qualified, but domestic staff may not be adequately trained. The records of the induction training of temporary agency staff members are inadequate. Service users are satisfactorily protected by the service’s recruitment policy and practices for permanent staff. Service users’ individual and joint needs are well met by appropriately trained permanent support staff. EVIDENCE: The Registered Manager reported that the service currently has four permanent staff vacancies, which are 3 main grade support workers, and the second deputy position. A recruitment drive for support workers is to take place in January 2007 and the deputy’s post has been filled from January by a secondment from the ‘community team’. The Inspector examined a sample of staff rotas which were satisfactory. Short Break Services DS0000032384.V319787.R01.S.doc Version 5.2 Page 22 The Inspector examined the recruitment records for a member of the permanent staff. Details of her CRB were available but not her references, which are kept at Head Office. The Inspector also examined the induction training records for temporary agency staff that are used by the service. The induction programme that has been devised is very good but the records of who has undertaken the training were found to be incomplete. Requirement 10. The Inspector examined staff training records supplied to him with the Preinspection questionnaire. It was noted that the domestic assistant was not scheduled to receive any training in the previous year (2006) whereas all other permanent members of staff were. The Registered Manager responded that her training needs would be ascertained in an appraisal and her identified training needs would be added into the next year’s training summary. Requirement 11. The Registered Manager reported in the pre-inspection questionnaire that 4 out of 8 support staff members have obtained an NVQ level 2 or above in Care, with an additional two staff members currently undertaking the award. Short Break Services DS0000032384.V319787.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their families benefit from a satisfactorily run residential service. Service users and their families views are fully taken into account when planning the service, which is very flexible. The health, safety and welfare of service users is not adequately promoted or protected because of the current hot water problems. EVIDENCE: A Registered Manager is in post and he is currently undertaking the Registered Managers Award. The Inspector noted that the Registered Manager is not only responsible for the Shortbreaks respite service, but is also responsible for two day centres and the community scheme. Regulation 26 visits are taking place Short Break Services DS0000032384.V319787.R01.S.doc Version 5.2 Page 24 and reports of these are sent to the CSCI. Regulation 37 reports are also received by the CSCI as appropriate. The Inspector noted that a current insurance certificate is now displayed by the service. The Registered Manager reported that a new format has been designed for use as a service user quality assurance questionnaire. Also that feedback forms are sent home with service users after each stay, for parents to complete. In addition, carers/relatives lunches regularly take place at the Shortbreaks premises. A peer advocate is also being used. The various aspects of feedback are then fed into a Service Development Plan. The Inspector examined the 2006/07 version. The quality assurance process and the flexibility of service development are commended. The Inspector examined the hot water temperature records. These showed that problems with the hot water supply continued with some areas of the premises consistency receiving water that was too hot, and other areas receiving water that was too cool. The records were also found to have gaps in them in that during two recent months, checks had not been undertaken weekly as the records system required. See Requirement 12. As reported in the ‘environment’ section (above), the problem is believed to with the water pressure and action is being taken to put matters right. The Inspector examined a Water Regulations report that demonstrated that the water supply was not yet fully compliant with those regulations. See Requirements 13 and 14, which are restated. The continuing faults with the hot water system have infection control implications as well as health and safety implications. A risk management process is required. Requirement 15. The Inspector examined the contents and records for a first aid box, which were satisfactory. A detailed and thorough risk assessment of the premises is in place. Short Break Services DS0000032384.V319787.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 x 3 3 4 x 5 1 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 1 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 3 x 4 x x 2 x Short Break Services DS0000032384.V319787.R01.S.doc Version 5.2 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5(3) Requirement Timescale for action 01/04/07 2. YA14 3. 4. YA18 YA24 5. 6. YA24 YA24 7. YA24 A letter, contract, or statement of terms and conditions, sufficient to meet this regulation, must be sent to each service user’s family, confirming the details of the service being offered following the assessment of need. 17(2) An adequate record of activities undertaken each day must be kept. THIS IS RESTATED FROM THE PREVIOUS INSPECTION. Sch3(2),17(1)(a) The care home must have a photograph of every service user. 23(2)(b) All the bedroom maintenance issues identified in the text must be corrected. 16(2)© The free-standing wardrobes must be replaced. 13(4)(a) All exposed hot water pipes must be boxed in where they create a potential hazard to service users. 23(2)(p) The lighting on the first floor corridor must be DS0000032384.V319787.R01.S.doc 01/02/07 01/03/07 01/06/07 01/06/07 01/06/07 01/06/07 Short Break Services Version 5.2 Page 27 improved. 8. YA30 23(2)© The refrigerator on the first floor must be made fit for use or take out of service completely. Hot water at the correct approved temperature must be provided to all parts of the care home. The registered person must ensure that all staff working at the care home receive training (including induction training for temporary staff) appropriate to the work they are to perform. THIS IS RESTATED FROM THE PREVIOUS INSPECTION AS THE TIMESCALE WAS NOT MET. All staff (including domestic staff) must have their training needs assessed and met in a co-ordinated manner. Hot water temperatures must be recorded on a regular basis. THIS IS RESTATED FROM THE PREVIOUS INSPECTION AS THE TIMESCALE HAS NOT BEEN MET. Evidence must be obtained to confirm that services and facilities comply fully with the Water Supply(Water Fittings) Regulations, 1999. THIS IS RESTATED FROM THE PREVIOUS THREE INSPECTIONS AS THE TIMESCALE SET WAS NOT MET. A Legionella testing certificate is required. THIS IS RESTATED FROM THE PREVIOUS INSPECTION AS THE TIMESCALE HAS NOT DS0000032384.V319787.R01.S.doc 01/02/07 9. YA24 23(2)(j) 01/04/07 10. YA35 18(1)© 01/02/07 11. YA35 18(1)© 01/03/07 12. YA41 17 01/02/07 13. YA42 23(2)(c) 01/05/07 14. YA42 13(4) 01/05/07 Short Break Services Version 5.2 Page 28 BEEN MET. 15 YA42 13(4) A documented risk management process is required to cover the issues of infection control and the danger of scalding, to cover the period that hot water at the recommended safe temperature is unavailable in parts of the premises. 01/02/07 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 Refer to Standard YA6 Good Practice Recommendations Each new care plan should be signed where possible by the service user, their representative or a family member, to demonstrate that consultation has taken place and agreement reached concerning the content of the care plan. Two additional hydraulic beds should be purchased for the benefit of support staff and service users with profound care needs. The damaged shower table in Bathroom 1 should be replaced. 2 3 YA24 YA24 Short Break Services DS0000032384.V319787.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Short Break Services DS0000032384.V319787.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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