Inspection on 10/06/08 for Southwell Road East

This inspection was carried out on 10th June 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southwell Road East 23/04/07

Similar services:

Hillside

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Southwell Road East 304 - 306 Southwell Road East Rainworth Mansfield Nottinghamshire NG21 0EB Lead Inspector Claire Williams Unannounced Inspection 10th June 2008 11.00 Southwell Road East DS0000068836.V366224.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 Southwell Road East DS0000068836.V366224.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. Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southwell Road East Address 304 - 306 Southwell Road East Rainworth Mansfield Nottinghamshire NG21 0EB 01623 482703 01623 482704 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) Nottinghamshire County Council Mrs Sarah Janine Bradley-Middleton Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Nottinghamshire County Council is registered to provide accommodation and personal care to people at 304 - 306 Southwell Road East, Rainworth, Mansfield, Nottinghamshire, NG21 0EB whose primary care needs fall within the following numbers and category: Learning Disability (LD) - 12. 23rd April 2007 Date of last inspection Brief Description of the Service: Southwell Rd east is a home providing care and support for up to twelve adults with learning disability. Some of the people also have a physical disability. The Nottinghamshire County Council (NCC) Local Authority manages the home and Nottingham Council Housing Association manages the buildings. The home is comprised of two separate bungalows, which have six bedrooms each. Each bungalow has its own communal lounge, dining room kitchen, laundry and toilet/bathroom facilities. There is an attractive and wellmaintained garden to the front and rears of each bungalow which people have access to. The home has equipment and adaptations to support people with physical disabilities. The fees are £351 to £398 per week. Information is provided in the Statement of purpose and Service user guide about what these fees include and what individuals have to pay for themselves. A Copy of the inspection report is available upon request from the office. Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for the service is one star. This means the people who use the service experience adequate quality outcomes The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views of the service provided. This process considers the service’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The inspection visit was unannounced and took place over a period of 8 hours. The Registered manager is currently off sick and the visit was undertaken with the assistance of the deputy managers. In order to prepare for this visit we looked at all the information that we have received, or asked for, since the last key inspection on the 11th April 2007. This included: • The annual quality assurance assessment (AQAA). This is a selfassessment that focuses on how well outcomes are being met for people using the service. • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • The previous key inspection report. • Surveys – we received feedback from 6 staff members who completed the surveys we had sent to them. Surveys were completed on behalf of the people who live in the service and 5 were returned. Assistance to complete these was provided by the staff team. During the site visit case tracking was included as part of the methodology. This involved the sampling of a total of three people’s files representing a cross section of the care needs of individuals within the home. Discussions were held with those individuals as able, and observations were made of the interactions between the staff and the people who live in this service. Individuals care planning and associated care records were also examined and their private and communal facilities inspected. Discussions were also held with staff about the arrangements for their care and also for staffs’ recruitment, induction, deployment, training and supervision. What the service does well: People are confident that the service can support them, as comprehensive assessments are undertaken before people move into this service. Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 6 Systems are in place to enable people or their representatives to raise any concern. People said they like where they live because “it is nice, clean and homely”. The staff team are trained motivated and committed to their role in supporting people. Staff members have access to positive training opportunities to enable them to have the skills and knowledge to fulfil their responsibilities. Quality assurance systems are in place to ensure the service is managed in the best interests of the people who live here. What has improved since the last inspection? What they could do better: The documentation in place would benefit from being reviewed to include the six strands of diversity, which are: race, gender identity, disability, sexual orientation, age, religion and belief. This will make it inclusive to all people. Although support plans are in place the system would benefit from being simplified so that they are working documents that the staff can use and update accordingly. This is to ensure any changes are recorded as required and support plans are followed ensuring peoples needs are met. New guidance has been released about the storage of controlled medication in care homes. Therefore this service will need to obtain this guidance and take the required action to ensure they comply with the new regulations to ensure medication is stored safely. Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 7 The staffing levels and deployment would benefit from being reviewed in accordance with the dependencies of the people currently living in the home, to ensure sufficient staffing levels are maintained. Staff would benefit from training in the multi agency safeguarding procedures so they have the knowledge and skills to respond to any incidents that may occur and safeguard people. All communal toiletries need to be stored in people’s bedrooms to reduce the risk of cross infection and to maintain peoples dignity so they use their own items. Creams must be disposed of after 3 months to reduce cross infection. 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. Southwell Road East DS0000068836.V366224.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 Southwell Road East DS0000068836.V366224.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): National Minimum Standards 1, 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with sufficient information about the service in order for them, and their relatives, to make an informed decision about whether the service is right for them. EVIDENCE: In the self assessment completed by the provider they said; they have a good system to ensure prospective individuals and their representatives have information to enable them to make a choice about the home. Admissions process in place to enable them to make good decisions about their ability to support the prospective individuals needs. They said they would ensure all staff are provided with training to meet specific needs. At this inspection the service demonstrated that they do provide people with the following information; a Statement of purpose, service user guide, and a contract. However this information is provided in written format and only the complaints procedure is provided in an accessible pictorial format. This means that although people have the required information in order to be aware of their rights and the facilities available, it is not accessible to them. This information however is accessible to their families and representatives who advocate on their behalf. Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 10 It was reported that as part of the transitional process people are encouraged and have previously undertaken trial visits to the home in order to make an informed decision about moving into this service. There have been no new admissions, but it was reported that the service have the required documentation in place in order to undertake a comprehensive assessment of a persons needs and their compatibility. This is to ensure the placement is right for them and for the people currently living in this home. There is currently one vacancy in one of the bungalows and an assessment was due to take place for the following week. There was evidence in the 3 files examined to support that the individuals Care managers had undertaken pre-admission assessments to make sure the placement could meet their needs. There were no people accommodated at the time of the site visit with diverse cultural or religious needs. It would be beneficial however for all documentation to be reviewed considering the six areas of diversity, so that is it inclusive to all people. Southwell Road East DS0000068836.V366224.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): National Minimum Standards 6,7, and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People had support plans in place to ensure their needs and choices were met. However due to the volume of information that was in place, these plans were not used as working documents which could impact of the delivery of care provided. EVIDENCE: In the self-assessment we received they said; they undertake assessments to build support plans for residents to ensure service users needs and choices are met. They record in running records and service user files. Service user care plans are in a more accessible format. The files for three people were examined. Each file contained support plans, which covered a variety of areas, which were applicable to the needs of the individual. All support plans were detailed and were recorded on an accessible pictorial format. Support plans were in place, which identified the persons Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 12 preferred communication style. This ensures staff are aware of the method of communication that should be used in order to enable the person to lead a full life that promotes independence and choice. The files in place were comprehensive with some files containing over 26 support plans. Discussions with the staff team indicated that due to the amount of information in place, the support plans were not referred to, or used as a daily working document. This was confirmed as only a small number of staff had signed each plan as requested due to the volume of information in place. When we examined the files it was identified that there was duplicate plans in place and some information was still in the files that was from a persons previous placement. Therefore it was confusing as to which plans contained the most recent information. Staff also reported that it was difficult to know where to record “new” information as some support plans were about the same area of need. This could result in staff not being aware of a change in need as the information has a potential to be missed due to the amount of support plans in place. In order to make information more accessible the deputy manager has developed a small file containing pen pictures of each individual including a photo of them. This information was accessible and person centred and provided a brief overview of each person’s support needs. It was reported that this file is provided to new and agency staff so that they are aware of each individuals support needs as a quick reference guide. Observations of staff practices and discussions demonstrated that the staff members had a good knowledge of individual needs and their preferences of how they wish to be supported. There is a stable staff team in place, which means they have developed long working relationships with the people who live in each bungalow. This means that consistent care is being provided and outcomes for people are not being affected due to the complex care planning system in place. People are supported to take risks to enable them to stay independent and staff have access to information on how to provide this support as each support plan had a risk assessment linking in with it. However as mentioned the amount of information in place could hinder staff members retaining the information, and there was some duplication in the risk assessments in place, which has the potential to confuse staff as to which assessment to follow. Observations supported that people are encouraged to make choices and are consulted on all aspects of their life. Individuals are encouraged to make decisions in accordance with their capabilities. One person who we spoke with said: “I like it here it is nice”. Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 13 People are supported to manage their own finances and each person had support plans in place for this. Systems were in place for the safekeeping of people’s finances and these was checked and found to be satisfactory. It was reported that staff have not attended training in person centred planning and staff reported that they would welcome this training as it would benefit them in their role. Training was being planned for staff in relation to the mental capacity act, and deprivation of liberty. Following this training it was reported that support plans would be developed to reflect individual’s capacity to make decisions about aspects of their life. This is in accordance with the requirements of the mental capacity act. Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 14 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): National Minimum Standards 12, 13, 15, 16, and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have access to recreational activities, which meet their individual preferences and expectations EVIDENCE: In the self-assessment we received they said; they are committed to enabling service users to enjoy and experience a good quality and fulfilled life. They offer opportunities for people to engage in community activities and welcome their families to the home at any time. The staff are committed to ensuring service users privacy, dignity and choice and they are offered a varied choice of foods at mealtimes and offered support with eating if required. Information was provided on an activity record of all of the activities and experiences people have access to. This demonstrated that people have access to community facilities and undertake various activities such as, visits to the park, theatre, local pub, and trips out to various locations. Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 15 Support plans were in place in relation to leisure activities but they were limited in detail as to what individual’s hobbies, interests and aspirations were. Therefore these would benefit from being more person centred. Majority of the people who live in this service attend a day centre for a couple of days a week. It was reported that on the days individuals are at home, they are supported to do personal shopping or to develop their independent living skills. However there was no evidence to support these activities or to support people’s weekly routines in their care plans. It was reported that people go away on holiday in small groups and there was many photos displayed of the variation locations visited. One person said “I have arranged my holiday for this year and cannot wait to go”. Staff supported some people to go out during this visit and other people were supported to undertake in-house activities that they enjoyed. Their was evidence in peoples files of the support provided to enable individuals to keep in touch with their family and friends. Observations supported that people’s dignity and rights are respected in their daily lives. A four-week menu was in place and this identified that one choice was available at each mealtime, however it was reported that people do have choices and this was demonstrated on the day. The menu is in written format which means it is not accessible to people. It was reported that the future aim was to develop a pictorial menu to enable people to be able to have an informed choice about what food they would like. Observations of the lunch and evening meal supported that choices were offered, individual dietary needs were catered for and people were supported in a dignified and respectful way to eat their meal. Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 16 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): National Minimum Standards 18, 19, and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People receive personal support from staff in the way they prefer and want. However gaps in the support plans could compromise people’s healthcare needs being met. EVIDENCE: In the self-assessment we received they said; they support service users with personal care if needed based on assessed needs. They ensure that all healthcare appointments are met and followed up if required. Regular medication review with GP. Medications are administered by trained staff and are administered in the service users preferred method. Each file that we examined contained various support plans, which covered all of the person’s healthcare needs. However as mentioned previously there were support plans that contained the same information, therefore there was a lot of information that was duplicated. It was clear from the records that each individual is supported to attend medical appointments, and the outcomes of these visits were recorded. Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 17 When we examined the files we identified that although a support plan stated that a person’s weight must be monitored and recorded monthly (due to a healthcare need) this had not been undertaken as the last recorded weight was in April. Following an annual medication review one person had been prescribed a new medication and although this was recorded on the evaluation sheet, the information had not been transferred to the medication support plan. This has the potential of people’s healthcare needs not being met as the support plans and records were not being updated or followed. Staff members reported that they do attempt to keep all records updated but due the volume of support plans in place it was difficult to maintain. Peoples that were able to communicate verbally said they receive personal support from staff in the way they prefer and want. Information is provided in each person’s plan concerning their routines and preferences enabling the staff team to provide appropriate support. Each person had 3 support plans in place regarding medication and the information provided did inform staff on how each individual likes their medication to be administered. Examination of the medication records demonstrated that people receive their medication as prescribed. We did identify that two people had not validated all handwritten medication instructions and this was addressed on the day. It was also identified that staff were not recording the number of tables administered when there was a variable dose. All staff have had medication training and an assessment of competence undertaken and records were in place to support this. Information was provided concerning the new guidance about the storage of controlled drugs as the service does not currently meet the new specifications. In response to the requirements made in the last report a system is now in place for the secure handling of the medication keys and it was reported that the medication policy has been updated to reflect the procedures of the home. Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 18 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): National Minimum Standards 22, and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Procedures for handling complaints and safeguarding were in place, however staff had not received training in these, which could compromise people being safeguarded if they are not responded to appropriately. EVIDENCE: In the self-assessment we received they said; they have procedures in place to ensure that service users are listened to. Any complaint is acted upon. Service users are protected from neglect, abuse and self harm and we have in place an untoward incident reporting procedure and NCC Health & Safety reporting policy. The complaints procedure was displayed in an accessible format for the people who live in this service. If people have concerns about their care they or people close to them know how to complain. The complaint records demonstrated that all complaints are responded to within an agreed timescale. The service has received one complaint since the last inspection and this has been responded to. A copy of the local Multi-agency safeguarding procedures was displayed and it was reported that policies and procedures in relation to abuse, and whistle blowing, were in place. The records seen demonstrated that all staff have had training in safeguarding either as part of their induction or through completing this subject as part of gaining a National Vocational qualification (NVQ) Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 19 During discussions with the staff members they all demonstrated their knowledge on what actions to take in the event of witnessing a potential abusive situation and all staff would report any incidents. However staff members were not clear about the multi-agency procedures and they did not know who would take the lead to investigate any incidents. It was reported that the manager would respond to this but the manager is currently on sick leave, therefore the senior members of staff would have to respond to any situations that arose. We went through the procedure and the staff on duty now have some awareness of who they would need to contact in the event of a situation being reported. There have been no safeguarding adult referrals and investigations since the last inspection Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 20 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): National Minimum Standards 24, 25, and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a homely and comfortable environment that was well furnished and maintained. EVIDENCE: In the self-assessment we received they said; all service users live in a safe, clean, comfortable and homely environment. They said they work well with the Landlord to ensure the environment meets individual needs. Both bungalows were visited and both were homely and well maintained. People gave us permission to view their rooms, which were personalised to their preferences and decorated to a good standard. People spoken with made the comments: “I like my room it is very comfortable”, “I’ve done my room the way I want it and its nice”. Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 21 People were observed using all areas of the home as all areas are accessible and on one level. It was reported that people have the required equipment to assist them with their mobility. Each bungalow has patio doors, which lead out to a paved area and to the secure garden. There was seating available and a variety of plants located in this area making it homely. The grass was quite long and would benefit from being cut and it was reported that this would be done within the next few weeks. All doors are now fitted with door closures, which means they can be kept open and would close if the alarms were to be triggered. This is in response to the requirement made previously about using wedges to keep doors open. The kitchen identified in the last report has also been upgraded. Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 22 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): National Minimum Standards 32, 33, 34, and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported by staff that are appropriately trained and recruited to ensure they are safeguarded. However insufficient staffing numbers could compromise the delivery of care. EVIDENCE: In the self-assessment we received they said; Service users are supported by a competent and qualified staff team. Their staff undertake training to support individual requirements. Mandatory training when required. Staffing levels are maintained at appropriate levels. The recruitment files for 3 of the most recently appointed staff members were examined. Each file contained all of the recruitment information that is required by the current regulations in order to protect people that live in this home. The staff team is stable as all of the staff have worked in the home for a long period of time. It was reported that 2 new staff are currently being recruited in order to cover staff members that are off sick. Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 23 Each staff member had training records in place, which included the certificates of the training undertaken. This demonstrated that staff had undertaken all of the required mandatory training and refresher training equipping them with the skills and knowledge to meet people’s needs. All new staff undertake an skills for care induction, specialising in working with people with learning disabilities. The discussions with staff members and the records demonstrated the commitment towards obtaining a national vocational qualification and many staff have already achieved a level 2 and are working towards a level 3. During discussions with staff members they demonstrated their commitment to developing their skills and knowledge and staff members welcomed any training that could assist them with their role. Staff said they have supervision and regular team meetings are facilitated; records in place supported this. However the frequency of supervision had decreased as a result of the manager being off sick and the deputies trying to cover the role in addition to their own. People spoke positively about the staff team and the following comments were made: “they are good and help me when I need it” “the staff are nice and friendly and help me when I need them to”. Observations supported that the staff members had a good knowledge of peoples support needs and provided assistance in accordance with peoples preferences. Issues were raised in the previous report concerning the staffing levels and there was no evidence to indicate that an assessment of people’s dependencies had been completed to determine if the staffing levels were in accordance with these. The staffing levels continue to be the same as the last time we visited, with two members of staff working in each bungalow and one member of night staff. However it was reported by the service manager who we spoke to after the inspection, that a review of the staffing levels was to be undertaken in the near future. Staff continued to raise concerns and in particular in relation to one bungalow where people had high dependency needs that require the assistance of two people to undertake person care tasks, and one to one support for eating and drinking. This means that people are not supervised when support is provided to these individuals. It was also reported that individuals have to go to bed before 9pm which is when the night staff arrive on duty as two people are required to use the equipment in place. Concerns were identified, as there is no system or procedure in place for responding to emergencies during the night. If a person needs to go to hospital a formal on-call system is currently not in place. Therefore the night staff telephone staff members who live near to the service in order to escort the person to go to hospital. This is not a planned intervention and is reliant upon Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 24 the availability of the staff. This could result in individuals having to wait for medical assistance until a staff member is available to support. On the day of the visit there was a staff shortage in one bungalow and only one member of staff was on duty between the hours of 4pm and 7.30pm. Arrangements had been made for the night staff member to commence their shift earlier but no other cover was arranged for this period of time. This means that in one bungalow people were not supervised when this staff member was completing tasks or assisting individuals with personal care. Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 25 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): National Minimum Standards 37, 39, and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service is not managed to ensure the health and safety of individuals is promoted and safeguarded. EVIDENCE: In the self-assessment we received they said; they consider that service users do benefit from a well run home. All testing is done and up to date. We underpin health and safety and welfare of our residents by ensuring that risk assessments are carried out for activities and where needed transfers etc. Regulation 26 visits. Regular supervision of staff and management team. The Registered manager is currently off sick and the deputy manager is trying to familiarize herself with the responsibilities that are part of the manager’s role. A new deputy manager has been in place for a week and she is trying to Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 26 familiarise herself with this role in order to support her colleague. It was reported that the service manager provides support and is available at all times for assistance. Although these arrangements are in place, we were informed that the staff morale was low due to there being a lack of direction and leadership. Feedback from the surveys received indicated that the staff team did not feel supported or valued in their role and issues around leadership were also raised. This has the potential to effect outcomes for people due to the morale of staff and the limited availability of daily support and guidance being provided. The service has kept us informed of any significant events, but when we went through the accident and incident file, it was identified that an incident had not been reported to us, but this was addressed straight away. Although the service manager was reported to visit the service regularly a report of the visit was not in place on a consistent basis for each month. These visits are required in order to monitor the standards in place and the general well being of the people who live in the service. During a tour of the building we identified many toiletries that were located in the communal bathroom. No items had names attached to them; therefore it was difficult to ascertain whom they belonged to. One item was a large tub of cream that had been opened but had past its expiry date of 2006. By people not having their own set of toiletries this could lead to cross infection and it means people dignity is not being maintained. These concerns were raised and it was reported that action would be taken to address these issues. The people who live in this service have high dependency needs and some individuals do not communicate verbally. However it was reported that people have families who advocate on their behalf and independent advocates are currently being used. It was reported that surveys had been sent to people’s representatives and a report of the feedback provided has been completed and this was examined. The self-assessment and a sample of the health and safety systems and service records confirmed that the building was a safe place for people to live. Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 27 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 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 2 X 3 X X 2 X Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 28 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 (1) Requirement Person centred plans must be kept under review and updated accordingly when a change in need has been identified. The plans must be accessible and used as working documents by the staff team to ensure people’s needs are met in accordance with their preferences. Support plans detailing peoples healthcare needs must be followed and completed to ensure individuals needs are being monitored and met The storage for controlled drugs must comply with the royal pharmaceutical requirements. This is to ensure medication is stored in accordance with the law. All staff must have training in the local multi-agency safeguarding procedures to ensure they respond appropriately to any incidents and protect people who live in this service. An assessment of the staffing levels and dependency needs of people must be undertaken to DS0000068836.V366224.R01.S.doc Timescale for action 01/10/08 2. YA18 12 (1) (a) 01/09/08 3. YA20 13 (2) 01/09/08 4. YA23 13 (6) 01/08/08 5. YA33 18 (1) (a) 01/09/08 Southwell Road East Version 5.2 Page 29 6. YA42 13 (3) ensure sufficient staff are on duty at all times in order to ensure peoples needs are met. People must use their own toiletries, which should be stored in their bedrooms, and creams must be disposed off within 3 months of opening to prevent cross infection. This is to ensure peoples health and safety is being promoted. 01/08/08 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 YA3 Good Practice Recommendations The admission records should be reviewed to incorporate the following areas of diversity: race, gender identity, disability, sexual orientation, age, religion and belief. These areas should be completed for each resident. When staff have received training in relation to the mental capacity act, support plans should be developed for each individual detailing their capacity to consent in their daily lives. Information should be provided in peoples care plans of the activities, and hobbies, they like to participant in, and of any future aspirations. This is to ensure the staff team, can provide support and enable people to lead fulfilling lives. A procedure for an on call system during the night should be developed in order to enable the night staff to respond appropriately to any emergencies. The staff should access person centred planning training to enable them to implement support plans that are individualised. 2. YA6 3. YA14 4. 5. ` YA33 YA35 Southwell Road East DS0000068836.V366224.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Southwell Road East DS0000068836.V366224.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. 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