Inspection on 29/01/09 for Shrewsbury Road (267)

This inspection was carried out on 29th January 2009.

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

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

Other inspections for this house

Shrewsbury Road (267) 23/01/08

Shrewsbury Road (267) 07/03/07

Shrewsbury Road (267) 30/01/06

Shrewsbury Road (267) 25/10/05

Shrewsbury Road (267) 20/12/04

Shrewsbury Road (267) 12/07/04

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 19/06/2009.

CARE HOME ADULTS 18-65 Shrewsbury Road (267) 267 Shrewsbury Road East Ham London E7 8QU Lead Inspector Lea Alexander Unannounced Inspection 29 January 2009 1.00 th Shrewsbury Road (267) DS0000022850.V374269.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 Shrewsbury Road (267) DS0000022850.V374269.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. Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shrewsbury Road (267) Address 267 Shrewsbury Road East Ham London E7 8QU 020 8586 7781 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) maria.dziedziurska@saharahomes.co.uk Sahara Homes Limited **Post vacant** Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can accommodate one named service user over the age of 65. Date of last inspection 23rd January 2008 Brief Description of the Service: 267 Shrewsbury Rd is a residential home run by Sahara Homes (UK) Limited, which also runs similar homes in the area, and provides long term care and support on a 24 hour basis for four people with learning disabilities. The home states that its purpose is to support, encourage and enable each resident to realise their full capacity in choice, dignity, respect, privacy, independence, civil rights and individuality. The home is a large terraced house situated in a residential street in Forest Gate. Service users have single bedrooms with hand-basins. There is a kitchen/dining room, bathroom and shower room and a paved garden at the rear of the house. The home is within close proximity to East Ham and Green Street shopping areas and served by a range of bus routes, Upton Park and East Ham underground stations. Off-street and on-street parking is available. Current fees are in the range of £900-£1,200 per week. Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this inspection over the course of a day. During the inspection we spoke residents, staff and the Manager. We also looked at paperwork relating to the running of the home, including resident’s personal files and staff personnel files. The home completed and returned its Annual Quality Assurance Assessment within the required timescales. The quality rating for this service is 0 stars. This means people who use the service experience poor quality outcomes. What the service does well: Two residents were at home when we visited the service. One of these told us that they “like it here” and that “staff are nice”. A second resident has limited verbal communication. We did however observe them periodically throughout the day and noted that they appeared relaxed and happy. The home regularly reviews resident’s individual plans. People who use the service are appropriately supported to manage their finances, and all transactions are recorded and supported by receipts. Residents are encouraged to participate in regular residents meetings. Some residents attend day centres and others are encouraged to develop their individual interests on activities within the home. People who use the service are supported to maintain contact with their families. Residents are supported with personal care in accordance with their needs and wishes. Residents are also supported to access a range of healthcare services. The home has sound medication administration practises. It has also developed appropriate complaints and safeguarding policies and procedures. Staff have received safeguarding training and demonstrated a good understanding of safeguarding issues. People who use the service benefit from a comfortable, well-maintained environment with a range of private and communal spaces. Residents have their own bedrooms that they are encouraged to personalise. Staffs are encouraged to undertake NVQ training. Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Seven requirements from the previous inspection are restated. These include the need for the home to produce new care plans when needs change, rather that annotate them by hand. Periods of 1:1 supervision for residents should be clearly identified. The home must also ensure that it fully implements its own safeguarding plan, and that full details of staffing reviews are supplied to the Commission for Social Care Inspection. Two satisfactory references must be obtained for all staff, and volunteers should be subject to Criminal Records Bureau (CRB) checks. All staff must receive specialist learning disability training. The outcomes of the homes quality assurance process should be collated and made available to interested parties. A further eleven requirements made as a result of this inspection. The home must ensure that identified risks are appropriately assessed and managed. The home should develop more personalised community based activities based on individual interests and abilities, and residents should be appropriately supported to access the community. Where residents are required to make healthcare decisions the home must evidence the decision making process and consider the use of medical advocates. All complaints must be recorded and investigated in accordance with the homes complaints procedure. The staffing rota should clearly indicate which staff will be on duty at which times, including the Manager. Sufficient numbers of staff must be rostered on duty within the home. Fridge and freezer temperatures must be maintained within acceptable parameters. Weekly fire alarm call point tests and regular fire evacuation drills must be carried out. Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 7 Two good practise recommendations were also made as a result of this inspection. To ensure the health and safety of people who use the service a small supply of sugary foods should be maintained in the medicine cupboard for administration should the diabetic resident experience a hypoglycaemic episode. 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. Shrewsbury Road (267) DS0000022850.V374269.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 Shrewsbury Road (267) DS0000022850.V374269.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has developed a statement of purpose that reflects the service provided. EVIDENCE: There have been now new admissions to the home since the last inspection. We looked at the homes statement of purpose. This has been updated since the last inspection to include the current Managers details. Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are involved in some of the homes day-to-day decision-making processes. Staffs are aware of the communication needs of residents. Individual person centred plans have been introduced since the previous inspection, but the home must ensure that identified needs and risks are appropriately addressed. EVIDENCE: We looked at the personal files of two residents. Since the last inspection the home has introduced a new format person centre plan for each resident. This is a clearly laid out, easy read document that addresses a range of social, personal and healthcare needs. Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 11 For one resident a handwritten footnote had been added to their plan identifying they were at risk from falls. There was no other information about the residents needs in the mobility section of their person centred plan. The plan for the two residents we case tracked was evidenced as being reviewed at least every six months. The last inspection had required the home to produce a new care plan when residents needs change, rather than add handwritten notes. This would make the plan easier to follow and ensure that only the most up to date information was recorded. Although the new format plans had been introduced these had been annotated with hand written notes. Whilst we were at the home we looked at the personal file for a resident who had been receiving 1:1 supervision at the time of the last inspection. We asked the Manager whether this service was still being provided, but they were unable to tell us. We also looked in the residents file, but could not find any information about 1:1 supervision. We later received information from the home evidencing that 1:1 support is no longer provided for this resident. Both of the residents we case tracked are older woman who have been receiving residential care for a number of years. Whilst their new plans are more person centred, there was little evidence of life story or the recording of significant events for either. Both residents were found to have been assessed for a number of risks identified within their person centred plan. We looked particularly at the risk assessment for the resident with the footnote on their person centred plan about the risk of falls. Whilst we did find a risk assessment for this on file, we were of the view that it was very brief and did not adequately assess the risk or identify a management plan to manage the potential risk of falls. Both of the residents we case tracked have a learning disability, and one resident is also diagnosed with dementia and has communication difficulties. There was not however anything in the person centred plan that reflected upon the residents ability to make decisions or choices for themselves. The Manager told us that three people who use the service have their own bank accounts. One resident is subject to appointeeship and dos not have their own bank account. The home has satisfactory arrangements in place with residents to support them with their finances. The agreement of residents the home holds small amounts of cash on their behalf that they can withdraw at any time. We looked at the financial records available for two residents. Each had a logbook detailing the date, amount and nature of the transaction. Receipts for each Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 12 transaction were also available. Separate personal files containing all correspondence relating to financial matters were also seen. We viewed the homes minutes of residents meetings. This evidenced that regular twice-monthly meetings are held and that residents have the opportunity to discuss activities they would like to undertake and day-to-day matters relating to the running of the home such as shopping. Shrewsbury Road (267) DS0000022850.V374269.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 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to maintain family links and to engage in meaningful activities inside and outside of the home. Residents are also engaged in the domestic routines of the home. The menu is varied and residents enjoy the meals provided. The home should develop community activities in line with resident’s individual abilities and interests. EVIDENCE: Discussion with the Manager, care workers and people who use the service evidenced that two people who use the service regularly attend day services. Three residents attend a bingo session once per week. The Manager told us that residents can also attend the Gateway social club each Tuesday evening Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 14 and a monthly disco. Residents are also supported to engage in activities within the home. During our visit we observed that one resident was knitting. A second resident who was at home was observed engaged in a colouring activity. Residents are also encouraged to engage in daily living activities around the home. One resident told us that they would “like to go out more”, and we formed the opinion that development of life story work as part of the care planning process and monthly key working sessions could identify more individualised community activities for residents to engage in. Discussion with people who use the service, and with care workers and the Manager along with sampling of personal files evidenced that where residents have families they are supported to maintain contact. During the course of the inspection staff were observed interacting with residents. Residents were observed choosing when to be alone or in company, or whether to join in an activity or not. We spoke with residents, care staff and the Manager. They told us that Residents meet once a week to decide what meals will appear on the menu for the coming week. Staffs use pictures of meals to help residents choose what they would like to eat, and to illustrate the final menu. The resident we spoke to told us that they “liked the food”. Shrewsbury Road (267) DS0000022850.V374269.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 good. This judgement has been made using available evidence including a visit to this service. Residents are supported with personal care according to their needs and wishes. The home has a efficient medication policy supported by good medication practises. Residents are supported to access a range of healthcare services. EVIDENCE: We found that resident’s preferences for personal care were reflected in their plans. During our visit we observed that residents appearance reflected their personalities. Discussion with people who use the service evidenced that they choose their own clothes. For each of the residents we case tracked we found that the home maintained a record of the healthcare appointments they had attended along with the outcome and any follow up. Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 16 We looked at the homes medication policy and procedure and found that this complies with National Minimum Standards. The policy also contains guidance relating to residents who are able to self medicate. We checked the actual medication available for two residents against that listed on the Medication Administration Record (MAR) and found that the two corresponded. The MAR sheets we saw were correctly completed and in good order. One resident is diabetic. From discussions with them, with care staff and by sampling their personal file we were able to evidence that they self-administer their insulin medication. This activity was reflected in the personal plan and had been appropriately risk assessed. The Manager told us that no residents are currently taking any controlled medications. A previous inspection had required the home to keep a specific stock of sugary foods to administer should a resident become hypoglycaemic. We were told that a general supply of such foods is kept within the home. We discussed with the Manager the incident from the previous inspection when the general supply of such foods had run out when the resident became hypoglycaemic. Shrewsbury Road (267) DS0000022850.V374269.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. Staffs have received safeguarding training and demonstrate a good understanding of adult protection issues. However, the home could not evidence that it had fully implemented its own safeguarding plan. The home has developed a complaints procedure in an easy read format. However, this is not prominently displayed and the home does not maintain a complaints log. During our inspection we found evidence of complaints being made to staff, but these were not recorded or investigated. EVIDENCE: The home has produced an easy read illustrated complaints procedure. It is kept in the entrance hallway to the home. On the day we visited the complaints booklet was not on display as it had been completely obscured behind a pile of other leaflets. We asked to see the homes complaints log. We were told that none was available. The homes Operations Manager subsequently told us that the home has revised the way it records complaints. We asked the resident we spoke with about complaints. They told us that they were “happy with the home”. We asked them what they would do if they wanted to make a complaint and they told us they would speak with staff. This resident could not recall having made a complaint in the past. Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 18 Whilst we were case tracking one resident, we noticed that their daily log indicated that they had complained about the service received in November 2008, when a trip out in the community had been cancelled at short notice. There was no record of this complaint being investigated, the action taken or the outcome. The Commission for Social Care Inspection has been advised of one safeguarding incident since the last inspection. This was investigated by the local authority and not proven. The homes training records indicate that all three of the permanent care staff received safeguarding training in September 2007. The member of care staff on duty at the time of this inspection was able to demonstrate a sound understanding of safeguarding issues and their responsibilities should they have any safeguarding concerns. The home produced its own safeguarding action plan in January 2008. We asked to look at this to review progress in its implementation. We noted that whilst the majority of points within this plan had been identified, there were three action points that we could not evidence as being implemented, the first being a review of staffing levels. This area is addressed in the “Staffing” section of this report. The safeguarding action plan also stated that staff would receive training related to person centred planning. We were not able to evidence that this had been provided to the homes three permanent care staff. Finally it was not evidenced that the home provided one takeaway and one restaurant meal per month at its expense to residents. We were subsequently told by the home that meals out are regularly provided to people who use the service, but that these are not claimed back through company expenses. Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable environment for people who use the service with a range of communal and private spaces. Residents have their own bedrooms, which they can personalise. EVIDENCE: The home is situated in a large terraced house. There is a large entrance hall with a communal lounge off of this. The lounge has a range of comfortable seating and there is a TV and stereo. The walls are decorated with pictures of residents. One resident’s bedroom is located on the ground floor, along with a shower room with WC and hand basin. A large kitchen diner with access to the garden is also located on this level. From the hallway there is access to a large cellar that is used for general storage including canned goods and a large freezer. Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 20 Access to the first floor is via a staircase and on the upper level 3 service users bedrooms, and two small offices are located as well as a bathroom with a tub and mixer taps, WC and hand basin. One person who uses the service showed us their bedroom. This was comfortably furnished with a bed, wardrobe and chest of draws. The resident had also been supported to personalise their bedroom to reflect their own life and personality. During the course of our visit to the home this resident was observed being supported by the Manager to choose new furniture for their bedroom. During the course of the inspection the homes premises were noted to be clean, hygienic and free from offensive odours. Shrewsbury Road (267) DS0000022850.V374269.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, 33, 34, 35 & 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care staff is encouraged to undertake NVQ level qualifications. Some staffs do are not up to date on core training, and no permanent care staff has received specialist learning disability training. It is not clearly evidenced that there are always sufficient staff rostered on duty, or that appropriate pre employment checks are carried out on all staff. Staffs do not receive a minimum of six supervisions in a year. EVIDENCE: The Manager told us that the home employs three permanent care staff. In addition care staff from a nearby sister home also cover some shifts. One member of staff is rostered on duty during day. On occasions a second member of staff may also be rostered on duty during this period. One member of care staff is rostered for a sleeping night duty. Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 22 The Sahara organisation operates a centralised personnel department. They retain personnel files and carry out pre employment checks. A signed summary sheet of the checks carried out is available on site for inspection. We looked at the available personnel records within the home for two care staff. For each the statement had been completed to evidence that an enhanced Criminal Records Bureau (CRB) check had been obtained. One staff’s summary sheet had also been completed to evidence that two references had been obtained. However, for the second care worker the statement had only been completed to evidence that one reference had been obtained. To ensure the safety of people who use the service the previous had required the home to obtain a CRB for a volunteer who visited residents. This was not available for inspection on the day we visited. The Operations Manager subsequently advised us that all staff and residents within the home had been advised that the volunteer was no longer able to visit the home in this capacity. We looked at the homes current staffing rota. The staffing rota for two homes was combined into one matrix making this difficult to follow. We also noted that some staff is rostered on duty for a night shift followed by a day shift, which could lead to a situation where one member of staff is on duty by themselves for a 24-hour period. The Manager is employed to run this and a nearby sister home. We unable to establish from the rota we were shown how many hours per week the Manager spends on site at this home. The previous inspection had required the home to review its staffing levels. We asked to see documentary evidence of this review. The Manager was unable to provide us with this during our visit. They did later email, and told us that staffing levels had been reviewed, and that an additional staff member was on duty at the home from 10am to 5pm five days per week. We did not receive a copy of the staffing level review, or information about who carried this out. As we received the information after we had completed our site visit we were not able to compare this information against a current staffing roster. Whilst examining one resident’s personal file we saw an entry that led us to query whether current staffing levels are sufficient. An entry in the residents file stated that a planned community visit was cancelled at short notice. The entry in their daily log evidenced that this was because only one staff member was on duty, and another resident who was at home at the time did not want to go out. The Manager gave us records of the core training completed by the three permanent members of staff in the last year. This evidenced that one care staff had completed 1 days training, a second had completed 1.5 days training Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 23 and a third had completed 2.5 days training. The training provided included moving and transferring, food hygiene and managing challenging behaviour. Two of the homes care staff were evidenced as having completed first aid training in 2007, however a third staff member was not evidenced as having received first aid training. None of the homes permanent care staff were evidenced as having received any specialist learning disability training since the last inspection. The training records showed to us by the Manager indicated that one care worker had obtained NVQ level 2 whilst a second care worker was currently studying for this. The third care worker has completed NVQ level 3. The homes Operations Manager advised us that care workers are paid whilst undertaking their NVQ level studies. We looked at the supervision records available for two care workers. These evidenced that one had received 3 supervisions in 2008 and the other had received 4 supervisions in the same period. The home subsequently submitted information to evidence that both care workers had received an appraisal in January 2009. Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 & 43. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Appropriate insurance cover has been obtained. However, the training and supervision of staff is inconsistent. A significant number of requirements from the previous inspection have been restated and it was not evidenced that the service has improved since the last inspection. A range of health and safety tests and checks that ensure the safety and well being of residents are not carried out regularly. Where tests and checks indicate that action is needed it is not evidenced that appropriate steps are taken to ensure the safety of residents. EVIDENCE: Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 25 At the time of this inspection a Manager had been appointed on a part time basis to manage the home, however they their post shortly after this inspection, and at the time of writing this report this post is vacant. We looked at the homes Quality Assurance file. This evidenced that two residents had completed feedback surveys on what it was like to live in the home in early 2008. We spoke to the Manager who told us that a survey for other stakeholders had been developed but not yet implemented. They also told us that outcomes from feedback surveys had been discussed at a Managers meeting, but that these had not been collated or published. We looked at the homes log of fridge and freezer temperatures. Whilst these were recorded on a daily basis we noted that the temperatures were outside of acceptable parameters in February, March and April of 2008 and on one occasion in January 2009. The fridge temperature had been recorded as 9 degrees on some occasions and the freezer temperature as –11 degrees. There was no record along side these entries to evidence what actions had been taken to restore the temperatures to acceptable levels. We also looked at the homes fire records. These evidenced that weekly fire alarm call point tests were not being carried out. There was a gap of nearly two months between testing from the 3rd August 2008 to the 5th October 2008. A further month lapsed before testing occurred again on the 3rd November 2008. Other shorter gaps of two and three weeks between testing also occurred in December 2008 and January 2009. In the records we were shown at the time of the inspection did not evidence that a fire evacuation drill had been carried out. The provider subsequently submitted additional records. However, we did not find these satisfactory, as the dates of the drills were unclear and the timings of the evacuations were not recorded. We looked at the homes record of water temperature tests. The temperatures recorded were within acceptable limits. However, records we were shown at the time of the inspection indicated that testing occurred infrequently, with no test recorded as having occurred since November 2008. The provider subsequently provided additional records, stating that from November 2008 a new log had been used to record these temperatures. We looked at this log and found that tests were recorded as having occurred weekly, with temperatures within acceptable limits. The home displays a current insurance certificate with appropriate cover. Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 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 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 1 3 Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 27 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 YA6 Regulation 15 Requirement Individual plans must adequately address identified needs such as mobility. Timescale for action 28/05/09 2. YA7 12 28/05/09 The home must demonstrate how individual choices have been made; and record instances when others have made decisions and why. This is a restated requirement. The previous target of the 30/06/08 was not met. 3. YA9 13 & 14 Potential risks should be subject to an appropriate risk assessment and management plan. The home should develop more personalised community based activities based on individual interests and abilities. People who use the service should be appropriately supported to access the community. 28/05/09 4. YA12 16 28/05/09 5. YA13 16 28/05/09 Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 28 6. YA20 13 Where residents are required to 28/05/09 make healthcare decisions the home must evidence the decision making process and consider the use of medical advocates. The home must ensure that all complaints are recorded and that they are investigated in accordance with the homes complaints procedure. The home must implement its action plan to safeguard people who use the service. This is a restated requirement. The previous target of the 30/06/08 was not met. 28/05/09 7. YA22 22 8. YA23 13 28/05/09 9. YA33 18 The home must notify the Commission for Social Care Inspection of the outcome of its review of staffing levels. This is a restated requirement. The previous target of the 30/06/08 was not met. The home must ensure that the staffing rota clearly indicates which staff will be on duty at which times within the home, including the Manager. The home must ensure that sufficient numbers of staff are employed within the home. 28/05/09 10. YA34 19 The home must obtain two satisfactory references for employees. This is a restated requirement. The previous target of the 30/06/08 was 28/05/09 Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 29 not met. 11. YA35 18 The home should provide specialist learning disabilities training to enable staff to better meet the needs of people who use the service. This is a restated requirement. The previous target of the 30/06/08 was not met. 12. YA36 12 & 18 Staff must receive a minimum of six supervisions in a year. This is a restated requirement. The previous target of the 30/09/08 was not met. 13. YA39 24 The outcomes of quality assurance should be collated and made available to interested parties. This is a restated requirement. The previous target of the 30/06/08 was not met. 14. YA42 13, 16 & 23 The home must maintain fridge and freezer temperatures within acceptable parameters. The home must carry out and record weekly fire alarm call point tests. The home must carry out regular fire evacuation drills with timings. 28/05/09 28/05/09 28/05/09 28/05/09 Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 30 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 YA19 Good Practice Recommendations Where there is a change in need a new care plan should be produced rather than notes added to the old plan. The home must ensure that appropriate procedures are in place to address healthcare needs, for example sugary foods must be available if a diabetic resident enters a hypoglycaemic state. Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Shrewsbury Road (267) DS0000022850.V374269.R01.S.doc Version 5.2 Page 32 - 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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