Inspection on 17/01/07 for St Marks

This inspection was carried out on 17th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Marks 20/11/07

St Marks 09/02/06

St Marks 03/08/05

St Marks 24/11/04

St Marks 17/06/04

St Marks 26/02/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 St Marks 23 Collier Road Hastings East Sussex TN34 3JR Lead Inspector Caroline Johnson Key Unannounced Inspection 17 & 18th January 2007 09:30 th St Marks DS0000021225.V322319.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 St Marks DS0000021225.V322319.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. St Marks DS0000021225.V322319.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Marks Address 23 Collier Road Hastings East Sussex TN34 3JR 01424 200854 01424 200854 23collierroad@tiscali.co.uk 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) A S D Unique Services Limited Position vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places St Marks DS0000021225.V322319.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of residents to be accommodated is six Residents will be over the age of eighteen on admission and below the age of sixty five Residents will on admission be diagnosed as suffering from autism Date of last inspection 9th February 2006 Brief Description of the Service: St Marks provides long term care for people over the age of eighteen who have been diagnosed as having an autistic spectrum disorder. This can include people with Aspergers syndrome. Each residents needs in respect of education and leisure time are assessed and a programme of activities arranged. The property is situated in a residential area on the West Hill of Hastings and is within walking distance of Hastings. St Marks is a three-storey building. There is no lift so residents need to be able to use the stairs. St Marks is one of four homes owned by the proprietors Mr and Mrs Kennard. The fees for the service range from £1,080 to £1,180 each week. Additional charges are made for hairdressing, toiletries, magazines and papers. Inspection reports are made available at the home and reference to the availability of reports is also included in the home’s statement of purpose. St Marks DS0000021225.V322319.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the inspection process site visits were carried out on 17th January from 9.30am until 6.45pm and on 18th January from 9.35 until 3.15pm. During the visits there were opportunities to meet with three of the residents and time was spent with the new acting manager and with four of the staff team. In addition one of the residents showed the inspector around the communal areas including the lounge/dining room, bathrooms, the kitchen, laundry area, activity room and their bedroom. A range of documentation was examined including care plans, risk assessments, health and safety records, medication, staff recruitment and training records, complaints, accidents and menus. Since the last inspection the registered manager has transferred from St Marks to work in another home owned by the company. A new manager has been recruited and had only started work in the home in December 2006. She had identified a number of areas that required attention and was beginning to formulate plans to address these areas. During the inspection an immediate requirement was made to consider the fitting of self-closing devices to some of the fire doors in the communal areas. Within a few days of the inspection the owners had confirmed in writing that this work had been addressed. As part of the inspection process comment cards were sent to the residents prior to the inspection to ask about their view of the service they receive. Three comment cards were returned to the Commission. In each case the resident received support to complete the forms. Residents chose to tick yes/no in response to questions rather than to provide comments. The outcome was very positive. However, one resident ticked that they did not know how to make a complaint, another ticked that they can usually make decisions about what to do each day and another ticked no for a question `can you do what you want to during the day’. A pre inspection questionnaire was also sent to the home for completion within a set timescale, however this has not been returned. What the service does well: The health care needs of the residents are closely monitored and when specialist advice or support is required then the home is good at making arrangements for this to happen. The residents have varied and stimulating activity programmes. Some of the residents have work placements and some attend college courses and day centres. In addition the residents make full use of their local community using local cinemas, pubs and shops. There are very good opportunities provided for staff to attend training courses and staff value this. All of the staff attend autism specific courses. Staff described their St Marks DS0000021225.V322319.R01.S.doc Version 5.2 Page 6 new manager as ‘open and supportive’ and all staff and residents spoken with were positive about the future. What has improved since the last inspection? What they could do better: As a result of this inspection 16 requirements and 5 good practice recommendations were made. This shows a significant fall in the standards that were in place at the time of the last inspection. The acting manager had already begun to identify shortfalls and was beginning to formulate a plan to address them. For the safety of residents, attention is needed to being more thorough in staff recruitment especially in relation to the need to carry out pova first (checking of names against the protection of vulnerable adults register) checks on all staff if they are to start work in the home prior to their full CRB (criminal records bureau) check being in place. All staff should receive regular supervision as a way of monitoring staff performance and to offer support and guidance to staff. In order to monitor how the home is running the owners must take over the responsibility for carrying out monthly, unannounced visits. In order to continue encouraging residents and their relatives to contribute their views on the running of the home improvements must be made to how the home responds to issues when they are raised through the quality assurance questionnaires and complaints. To safeguard against the risk of accidents/incidents occurring all perceived risks must be clearly documented along with the action to be taken to prevent such occurrences. Goals in care plans need to be more specific. The residents should be more involved in identifying their own goals and daily logs should be used to record all progress made. Improvements in record keeping in this area would highlight more clearly the good quality of work carried out by staff in supporting residents. Since carrying out this inspection the owners have confirmed in writing that they will take over the carrying out of monthly, unannounced visits to the home and that they will provide a written report to the Commission of their St Marks DS0000021225.V322319.R01.S.doc Version 5.2 Page 7 findings. They have also taken over the responsibility for staff recruitment and will ensure that detailed documentation is kept. 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. St Marks DS0000021225.V322319.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 St Marks DS0000021225.V322319.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): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. It is disappointing that no further progress has been made in the drawing up of the service user guide particularly as at the time of the last inspection part of the work had been completed. However, the residents’ charter is an excellent piece of work and each of the residents were able to contribute to the charter. EVIDENCE: There is a detailed statement of purpose in place, which now needs to be updated to include details of the changes to the management of the home. At the time of the last inspection work had begun on updating the service user guide and one of the residents was to take photos to be included in the document. The resident advised that he took the photos and that they were on the computer. The photos could not be found and staff spoken with confirmed that the document had yet to be completed. A residents’ charter has been drawn up and this includes various photos of the activities that the residents have participated in over the course of 2006. Some of the residents have also written about the activities that they participated in. St Marks DS0000021225.V322319.R01.S.doc Version 5.2 Page 10 There have been no new residents admitted to the home since the last inspection. St Marks DS0000021225.V322319.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): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. Care plans provide detailed information about the needs and abilities of residents. If goals set were more clearly defined it would be easier to record the action to be taken to meet them and to record all progress made. The recording of house meeting minutes needs to be more detailed showing how choices are presented to residents, how decisions are reached and how residents are able to contribute to the running of their home. EVIDENCE: Care plans contain very detailed information about each resident. In relation to one care plan, it was noted that there were several goals in place. However, when one of the goals was discussed with a staff member they stated that that goal was no longer being worked on. Another goal was about learning to use the washing machine. There was a task analysis stating the steps to be taken and then advice under the steps stating that the resident was independent in these areas and needed support with separating coloured clothes from whites. There was no evidence that the resident had agreed with the goals in place. However, the resident’s keyworker advised that they had discussed the goals St Marks DS0000021225.V322319.R01.S.doc Version 5.2 Page 12 with him. This resident would like to be more independent. Staff agreed that this resident has the potential to move on to more independent living in the future. However, it was not clear from the care plan what skills would need to be achieved in order to gain more independence and what progress was being made with short-term goals. The risk assessment for this resident using the kitchen had been in place since 2002, it had been reviewed annually but no amendments had been made. In another care plan a newly drawn up risk assessment was examined. Discussion was held regarding the wording used, as it was evident that the risks had not been clearly identified and therefore all action taken by the home was not recorded. The acting manager had ideas of how to simply the system currently in use and advised that she would be discussing this with the proprietor. Each week there is a residents’ house meeting and during this meeting the residents discuss house issues and each resident is given the opportunity to choose what activities they would like to do and what meals they would like. Records showed that most weeks, residents enjoy cinema outings, pub trips and walks in the old town. Residents spoken with stated that these were the main activities they enjoy at the weekends. Staff stated that when the weather improves activity choices are more adventurous. The format for recording the house meeting minutes had changed since the last inspection and the new format allows for more detailed information to be recorded in particular in relation to house issues discussed. However, this is not always used appropriately in that staff record the topics discussed but not the discussion that follows. Between the first and second day of inspection it was noted that staff did record a particular subject discussed and the fact that two residents had been against the introduction of a new procedure. Records did not state what action staff were going to take in response to the residents raising an objection. St Marks DS0000021225.V322319.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Residents lead very busy and active lives with good opportunities for participation in education, work, leisure and community based activities. Residents should be encouraged to come up with some more ideas for introducing more fruit and vegetables into their diet to maintain a healthy lifestyle. EVIDENCE: Each of the residents has an individual programme of activities. Programmes are varied. Two of the residents have a work placement, one for one hour a week and one for two hours a week. In addition residents attend college courses and day centres. They also attend activities such as gym, swimming, bowling and occasionally horse riding. Some of the residents do independent shopping, attend a social skills group and contribute to the home’s monthly newsletter. There are also regular opportunities for the residents also join up with friends from other homes with the company for social outings. St Marks DS0000021225.V322319.R01.S.doc Version 5.2 Page 14 Annual holidays were discussed with two of the residents. They stated that they were going to Norfolk Broads. When asked how they had decided on the destination both stated that the staff member had decided. The staff member advised that the previous year there had been indecision about two destinations, some of the residents had to compromise so it was thought that they should go to the second choice of destination this year so that everyone’s choice could be accommodated. Reference to this discussion could not be found in the house meeting minutes. During the year some of the residents went on a camping trip. Those spoken with stated that it had been the first time they had been camping and they really enjoyed the trip. They also enjoyed regular opportunities to go fishing and there were lots of photos showing each of the residents catching their first fish. A calendar was made with photos of the residents on their camping trip. Staff spoken with stated that they were starting to review some of the programmes as it is thought that some days are extremely busy and it is difficult to complete each of the tasks set. Staff also stated that they assist the residents to maintain contact with their relatives. In some cases there is a link book between the home and the family and this ensures that there is good communication. Menus are set for Monday to Thursday and meals for the remainder of the week at decided at the house meetings. There is a good range of meat, fish and vegetarian options. All of the residents spoken with stated that they were happy with the menus in place. One of the relatives had asked in the relatives’ satisfaction questionnaire if there could be more healthy meals served. On examination of the shopping lists linked to the menus, it was noted that most meals contain carrots or peas and occasionally broccoli and mushrooms. Apart from smoothies, one day a week there is no other fresh fruit on the menu, although it was noted that apples and pears are bought in regularly. Staff advised that the residents could be reluctant to eat fruit and vegetables. It was recommended that the home discuss the menus with the residents to try to come up with some more healthy options. St Marks DS0000021225.V322319.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The home is very good at ensuring that arrangements are made for the residents to attend healthcare appointments and to receive specialist input when required. There are good arrangements in place to ensure that the residents receive medication as prescribed however the system for documenting medication received into the home and returned to the pharmacy needs to be improved to safeguard against the risk of abuse of medication. EVIDENCE: Records seen of medication administered to residents were in order. There is a signing in/out book for medication given/received from relatives. It was noted that medication returned by a relative had been recorded in this book. Staff were confident that the medication had then been returned to their pharmacy but there was no written record that this had happened. There was medication in the cupboard that had been ordered as extra for a resident’s trip home and this had been returned but again, it was not clear if this was to be returned to the pharmacy. It was not possible to do an audit trail of medication from the time it is received into the home. There may have been records that could have explained the process but these could not be located. St Marks DS0000021225.V322319.R01.S.doc Version 5.2 Page 16 Staff spoken with confirmed that they had medication training last year. In addition the home has an in-house competency assessment. Staff are not allowed to administer medication until they have been assessed as competent to do so. Individual records show that residents attend a wide range of healthcare appointments as necessary to meet their individual needs. One resident received specialist support from the learning disability service for a short time during the summer but then chose not to continue to receive this support. It was noted that this resident who has a tendency to be self isolating is now spending more time in communal areas and responding well to prompting to attend to their personal care needs. Staff spoken with stated that having a specialist involved was very positive particularly as this resident has such complex needs and there are now clear guidelines in place for staff. St Marks DS0000021225.V322319.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. There are good procedures in place to ensure that anyone wishing to make a complaint can do so. Records of complaints made need to be more detailed so that it is possible to determine all areas of concern and any action taken by the home to address them. EVIDENCE: There is a policy in place detailing how complaints can be made. Complaint sheets were available so that anyone wishing to make a complaint could do so. Records showed that one complaint had been recorded. The complaint was made via telephone. The record stated that the caller telephoned regarding a number of issues. However, there was only one issue recorded. The record kept referred to the complainant not being happy with a letter sent to them via the home. Records stated that the letter was attached but there was no attached letter. The complainant did not want the issued treated formally and it was not clear if any action was taken regarding the issue. There have been no complaints made to the Commission about the home since the last inspection. With the exception of one of the staff spoken with everyone else had received training on the protection of vulnerable adults. There have been no adult protection alerts made to the Commission since the last inspection of the home. St Marks DS0000021225.V322319.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): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. With the exception of the downstairs toilet the standard of decoration is very good. Improvements also need to be made to reducing opportunities for cross infection and this can be achieved by reviewing facilities for hand washing and drying. A full review of the home’s fire risk assessment should be carried out periodically with details of any issues highlighted as a result. EVIDENCE: One of the residents took the inspector on a tour of the communal areas, their bedroom and the laundry area. A good practice recommendation was made at the last inspection of the home to redecorate the ground floor toilet. It was noted that this work has yet to be carried out. As well as liquid soap there was a bar of soap and the towel in use was of very poor quality. In order to reduce the risk of cross infection it was recommended that the bar of soap be removed. A new system for drying hands should also be explored that is in keeping with a homely setting. St Marks DS0000021225.V322319.R01.S.doc Version 5.2 Page 19 Records held in relation to fire safety showed that checks of the fire alarms are carried out weekly and emergency lights monthly. Fire drills are also held at regular intervals and the outcome is evaluated. The home should also include the length of time it takes to evacuate the home. There is a fire risk assessment in place dated 2003 and it was checked and signed as having been reviewed in 2005. It was not clear from the records if the individual had carried out a full review of each section or if it was more a review of procedures. On the first day of inspection it was noted that fire doors were wedged open and the home was advised that fire doors must be kept closed. On the second day of inspection it was noted that resident had been advised at the house meeting that the fire doors needed to be kept closed. Two of the residents raised an objection to this. Therefore an immediate requirement was made that the owners consider the action to be taken to ensure compliance with the Regulations. The owners responded immediately and self-closing devices were fitted to the doors. St Marks DS0000021225.V322319.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (poor) This judgement has been made using available evidence including a visit to this service. Standards in this area have reduced significantly. Recruitment procedures have not been followed appropriately, pova first checks have not been made, staff have not been regularly supervised and this could potentially have left residents at risk. There are good procedures in place to ensure that staff have regular training opportunities. EVIDENCE: Staff recruitment records were seen in relation to two members of staff. It was clear that the home were not following their recruitment procedures. There were unexplained gaps in employment history, discrepancies in dates of employment given and in some cases it was not clear who had written references. It was apparent that staff were given a job offer subject to satisfactory references and CRB. No pova first was being obtained but staff were working under direct supervision of more experienced staff or else not employed to work until the full CRB was in place. In relation to both files seen there were no records of supervisions having taken place, however one member of staff had had an appraisal. There was an opportunity to speak with one of these staff who advised that they had St Marks DS0000021225.V322319.R01.S.doc Version 5.2 Page 21 received regular support from their manager but no formal supervision. Both staff were due to have supervision on the days of the inspection. Other staff stated that supervisions have generally been carried out regularly but there had been some slippage since October 2006. The acting manager agreed to check that CRB checks have been carried out on all people who have access to the home including those that are employed to provide activities each week or to transport residents to activities. The home has a detailed induction package, which all staff are expected to complete. Staff advised that the package is linked to Skills for Care and that it needs to be completed within six months of starting work. Staff were not sure if the induction standards had been updated in line with the Common Induction Standards, which need to be completed within a twelve-week period. It was not clear at which point new staff commence working through the induction package. One member of staff who started working for the company in September as a relief member of staff didn’t start the home’s induction until they became a permanent member of staff in December. The home’s induction package made reference to the home being registered with East Sussex County Council rather than with the Commission for Social Care Inspection. A carer was asked who the home was registered with and their response was as stated in their induction package. With the exception of one member of staff, all staff spoken with were up to date with mandatory training and had attended a number of autism specific courses. Staff valued the training opportunities made available to them. The acting manager agreed to confirm how many staff have completed NVQ training and how many are currently studying. Two of the staff spoken with stated that they were studying towards NVQ level three. St Marks DS0000021225.V322319.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. As part of the home’s quality assurance system the home should continue to encourage residents and their relatives to have their say on the running of the home by responding to all requests for information and suggestions for change made in the satisfaction questionnaires. The owners should take over the carrying out of the monthly-unannounced visits to ensure that they have a clear picture of how the home is running. EVIDENCE: The new acting manager started in post in December 2006. Staff described her as ‘open and supportive’. She advised that arrangements had been made to have regular supervision with the providers and that she had attended two management meetings, which had been very helpful. She stated that she was still getting to know the staff, the residents and the company. She had yet to St Marks DS0000021225.V322319.R01.S.doc Version 5.2 Page 23 begin a formal induction to the service. The acting manager had identified a number of areas where improvements were needed and was beginning to formulate a plan to address them. Records showed that staff meetings had been held approximately every other month rather than twice a month, as is the home’s policy. Minutes since June 2006 are very brief with very little evidence of any discussion having taken place. Minutes of the last two meetings did not show the names of the staff present. Minutes of the meetings held in November and January were much more detailed. A residents’ satisfaction questionnaire was carried out in June 2006. Responses from the residents were collated and there was a feedback form on file. Records did not show if the outcome had been fed back to the residents. A relatives’ satisfaction questionnaire was carried out in April 2006. Overall the response was very positive. However, three of the relatives raised areas where they wanted further clarification and some suggestions for change were also made. Records showed that a written response was made to one relative but not all areas referred to in their letter had been addressed. There was no written evidence that a response had been made to the two other relatives. The company arranges for one of the managers from one of the other homes within the group to visit on a monthly basis unannounced and to report to them on the conduct of the home. Records showed that the last report was carried out in June 2006. Within the record there were dates of when staff had received supervision. The dates tallied with the planning dates but on checking with the actual dates supervision was provided it became apparent that there were some discrepancies with the dates given and some supervisions missed. As part of the inspection process comment cards were sent to the residents to ask about their view of the service they receive. Three comment cards were returned to the Commission. In each case the resident received support to complete the forms. Residents chose to tick yes/no in response to questions rather than to provide comments. The outcome was very positive. However, one resident ticked that they did not know how to make a complaint, another ticked that they can usually make decisions about what to do each day and another ticked no for a question `can you do what you want to during the day’. In relation to health and safety, it was confirmed that all portable appliances were tested in 2006 and that arrangements are being made for this to be carried out again. Carbon monoxide checks are carried out weekly. Records showed that hot water temperatures are tested and recorded regularly. One of the residents assisted the inspector with the monitoring of the hot water temperatures at two outlets, both outlets showed readings that were within agreed safety limits. St Marks DS0000021225.V322319.R01.S.doc Version 5.2 Page 24 It was noted that records of accidents for residents and staff are stored together and not removed from the accident book and stored confidentially. St Marks DS0000021225.V322319.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 X 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 2 X X 3 2 St Marks DS0000021225.V322319.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 6(a,b) Requirement The home’s statement of purpose must be updated to reflect the changes in the management team. In relation to one resident’s care plan, the home must review the care planning process to ensure that goals are mutually agreed and that they are specific, achievable and can be measured in terms of progress. Minutes of house meetings must show the action taken by staff when residents raise objections to how their home is to be run. In addition records should show when choices are given to residents and when residents choose differing options, how are decisions reached. Risk assessments must clearly define the perceived risk along with all action taken and to be taken by staff to minimise the risk of accidents/incidents occurring. It must be possible to do a complete audit of all medication received into the home. Where a complaint is made to DS0000021225.V322319.R01.S.doc Timescale for action 15/04/07 2. YA6 15(2) 31/03/07 3. YA7 12(2) 31/03/07 4. YA9 13(4) 31/03/07 5. 6. St Marks YA20 17(1a) 17(2) Sch 15/03/07 30/04/07 Page 27 YA22 Version 5.2 4 para 11 7. YA24 23(4a) 8. 9. YA27 YA30 23(2b) 13(4c) 10. YA34 19(1c) 11. YA34 19 Sch 2 para 1-9 12. YA35 18(1c,i) 13. 14. 15. YA36 YA37 YA39 18(2a) 9(1,2) 24(2) 16. YA43 26 the home a written record must be kept of all areas of the complaint and any action taken as a result. Records must show that a full review of the home’s fire risk assessment is carried out on a regular basis. The downstairs toilet must be redecorated. In order to reduce the possibility of cross-infection the home must review the procedures in place for hand washing and drying in the bathroom areas. Staff recruitment records must show that the registered person is satisfied on reasonable grounds as to the authenticity of the references obtained for prospective staff. Gaps in employment history must be discussed. POVA first checks must be obtained in respect of all new staff if they are to work in the home prior to obtaining a full CRB. All new staff (permanent and relief) must begin their induction to the home as soon as possible after appointment. All staff must receive regular supervision. The acting manager must apply for registration. The outcome of residents’ and relatives’ satisfaction questionnaires must be fed back all concerned. Where matters are raised, records must show details of any action taken by the home as a result. The owners’ must take over the responsibility for carrying out monthly, unannounced visits to the home and to provide a copy of their findings to the manager DS0000021225.V322319.R01.S.doc 31/03/07 30/04/07 31/03/07 30/04/07 15/03/07 15/03/07 15/03/07 30/04/07 30/04/07 15/03/07 St Marks Version 5.2 Page 28 and to the Commission. 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. 3. 4. 5. Refer to Standard YA1 YA17 YA32 YA35 YA38 Good Practice Recommendations The home should complete the updating of the service user guide. Explore with the residents ways of introducing more fruit and vegetables in their diet. The home should ensure that they remain on target to have 50 of the staff team trained to NVQ level two or above. The home’s induction package should be linked to Skills for Care and new staff should complete the package within twelve weeks of employment. Minutes of staff meetings should show details of each subject discussed and any decisions reached. A record should also be kept of all staff in attendance. St Marks DS0000021225.V322319.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 St Marks DS0000021225.V322319.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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