Inspection on 02/01/07 for Station House

This inspection was carried out on 2nd January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Station House 20/11/08

Station House 23/02/06

Station House 05/07/05

Station House 21/02/05

Station House 02/09/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Station House Station Road Admaston Telford Shrophire TF5 0AP Lead Inspector Deborah Sharman Key Unannounced Inspection 2nd January 2007 08:45 Station House DS0000020580.V294732.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 Station House DS0000020580.V294732.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. Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Station House Address Station Road Admaston Telford Shrophire TF5 0AP 01952 242648 01952 740262 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) Overley Hall School Limited Mrs Cheryl Elizabeth Jackson Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Date of last inspection 23rd February 2006 Brief Description of the Service: Station House is a detached property situated in Admaston, Telford. The home offers access to local amenities that include a post office, public house, grocery store, hairdressers and church. The property is in keeping with the local community. The home is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of four people with a learning disability. Ms Cheryl Jackson is the Registered Manager of the home. She has been employed by the organisation for numerous years before taking up the managers position at Station House in 1997. Fees are charged annually but are paid four times per year. The current lowest annual charge is £64,672.94 and the highest is £92, 250 Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced Inspection meaning that no one associated with the home received prior notification and was therefore unable to prepare. The inspection was also a key inspection meaning that the plan was to inspect the homes performance against all ‘key’ National Minimum Standards. One Inspector conducted the inspection, which started at 8.45am and finished at 5.15pm. The home’s Manager had provided pre inspection information to CSCI as requested but as a result of the Christmas leave period this was not available to the Inspector to use as part of the inspection planning process. However, the information including written comments from relatives, service users and professionals has been used within this report. Staff completed comment cards with and on behalf of service users. The responses are positive indicating that staff recognise from none verbal cues if and when service users wish to communicate a problem. No difficulties were indicated in the responses. Evidence to support judgements made about the service provided was collated by assessing a range of documentation during the inspection including care records relating to one service user whose care was assessed in detail. The Inspector was advised against spending time with the service user whose care was assessed in detail and with regard to his needs this was respected. Records of a second service user were sampled to assess some aspects of care provision. The Registered Manager was available throughout the inspection day to support the inspection and in addition the Inspector was able to talk to two staff members. The Inspector was also able to speak on the phone after the inspection to the person appointed to carry out monthly independent Regulation 26 visits to Station House whose role it is to form an opinion of the standard of care provided in the care home. The Inspector briefly met all four-service users who were individually introduced. Due to the nature of their disabilities service users could not verbally describe to the Inspector the level of their satisfaction with the service. However, observation showed them all to be happy, well groomed and familiar with staff and their environment. The Inspector was advised by the Manager at the beginning of the day that the Inspectors presence may distress service users as this was this Inspectors first visit to the home. The Manager felt that the Inspectors presence would compound service users existing agitation arising from the end of the Christmas break. However towards the end of the inspection day the Inspector was able to spend time with two other service users in their lounge. During this Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 6 time one service user was able to explain to the Inspector that he was ‘comfortable’ at Station House. Station House continues to provide appropriate care to service users who can be assured that their needs are met. What the service does well: Staff are provided with good training opportunities and are appropriately guided to meet service user need by good care planning systems. Service users’ personal care and health care needs are met well. Routine health screening is provided along with specific health interventions to meet changing health needs. An experienced and happy staff team have a good understanding of service users strengths and service users’ abilities are maximised. Systems are in place to ensure that service users are protected. The provision of a very comfortable and well maintained home further promotes their comfort and safety. Service users live in an environment that values them. The provision of outings and activities is a particular strength of the home and service users lifestyles are excellently supported. The home is well supported by the Provider and Manager. The home is well managed. Relatives and professionals who completed comment cards requested by the Commission for Social Care Inspection are very satisfied with the care provided at Station House. A relative wrote: ‘‘We are very pleased, at how well Station House is run and how happy X is, also how pleased we are at how well X is looked after’. A Doctor who is professionally associated with Station House but independent of it wrote: I am ‘‘VERY impressed with the quality of care and knowledge and attitude of staff towards clients’ Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Some requirements for improvement have been identified and agreed with the Manager as a result of this inspection. The home generally meets the dietary needs of service users well. But, how the home is meeting the cultural dietary needs of one service user must be better evidenced. Most aspects of medication management are also managed satisfactorily however improvement is required in relation to systems for the administration of medication prescribed as short courses e.g. antibiotics and those prescribed ‘as required’. There was some evidence that a short course of anti biotics had not been administered to the service user as directed. This does not enable the service user to gain maximum health benefits. As a result of this inspection the Manager has submitted a revised medication policy which the inspector will pass to the pharmacy Inspector for assessment and advice. Staff are experienced and are well trained. Previous improvements noted in the frequency of formal supervision arrangements of staff have however not been maintained satisfactorily. This inspection has noted the need to further improve the style and content of supervision too. The Manager had identified the need to address these issues. Although staff are experienced and well trained, systems are not satisfactorily in place to ensure that new staff are inducted appropriately to the National standard. The Manager must also ensure that incidents, which involve the physical restraint of a service user, are notified to the Commission for Social Care Inspection to ensure that such incidents, which affect the health and welfare of service users, can be monitored. Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 8 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. Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 9 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 Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 10 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): 2 Quality in this outcome area is good. A new service user was provided with a transition period. Although formal assessments had not been obtained or carried out with a view to admission, information was available to the Manager, as the new service user was known to the Organisation. The outcome of the placement is positive with the service user now settling well. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Prior assessments and care plans for a new service user were available pre admission to Station House as the service user was accommodated by the Organisation before the move to Station House. The service user also enjoyed a transition period prior to moving in to Station House where the Manager reassessed him upon admission. Meetings with the placing authority had also taken place prior to the service users admission. A good range of individualised risk assessments with clear control measures were carried out prior to the new service user moving in to maximise the service users safety. To the home’s credit, following a difficult start the new service user is now settling well and is making good progress. Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 11 Discussion with the person appointed to undertake monthly independent visits to the home verified that this new service user benefited from a transitional plan and several trial visits. Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is good. The service users needs are addressed in comprehensive care plans, which provide detailed guidance for staff with attention to service users strengths and abilities. There is clear evidence of service users being afforded choice and respect in their day-to-day lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans reflect service users assessed need and provide good detailed guidance to help staff meet these needs. It is positive that this guidance recognises the abilities, strengths and independence of the service user whose signatures have been obtained where permissions are required. Behaviour care plans provide staff with good advice about what triggers service users behaviour and required interventions to diffuse escalating situations based upon the principles of best interest. Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 13 The Manager stated that a 3-month review of a new placement had taken place with the placing authority but whilst there were minutes of a pre admission meeting none were available to evidence the second meeting. Records of care provided are detailed. Documentation therefore evidences practice being service user focussed with evidence how service users are encouraged to make choices and decisions as far as possible. Whilst this was evidenced in documentation – i.e. shift records, it is reinforced in care staff’s job descriptions and a new staff member who is new to the care profession was aware of the principles supporting practice. Clear individualised risk assessments had been carried out prior to the admission of a new service user to minimise identified hazards. Station House DS0000020580.V294732.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): 12, 13, 15, 16, 17. Quality in this outcome area is excellent. Service users are supported to lead full and active lives in accordance with their interests, preferences and needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An up to date activity plan is in place for the service user whose care was assessed. This plan was seen being adhered to on the day of inspection. Written and pictorial documentation shows excellent activity opportunities for this service user in line with his known interests. The range of outings is exceptional and included a trip to the coast on Christmas day. These opportunities were further verified through discussion with a staff member who confirmed the range of leisure activities and outcomes available to service users. Service users went out for lunch on the day of inspection. Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 15 College is also available to service users, one of whom attends three colleges per week. Staff support service users at college where necessary to ensure that attendance remains possible. Staffing levels are provided flexibly with one to one staffing provided when necessary to support service users community access. There is clear evidence of service users domestic skills and interests having been assessed. Records demonstrate that service users are encouraged to maintain these skills and do so enthusiastically. Family needs are assessed and individual family circumstances are known to the manager and are taken into account. All service users are from out of Borough so families live a considerable distance away and most are unable to visit. Whilst there was evidence of visits and phone calls from one family, the home endeavours to help others maintain contact by driving service users several times per year to meet their families. The staff also proactively tries to maintain links between service users and their families by sending letters and photographs by post. A new staff member who is new to the care profession had a good understanding of how to promote service users rights, choices, privacy, and independence. Care plans also demonstrate that the management and staff understand service users sexual needs. Varied menus that are influenced by service users likes and dislikes are in place. Whilst there is evidence of good dietary outcomes for some service users e.g. one person has lost 4 stone in two years by being supported to adhere to a dieticians advice, menus, food stocks and care records do not evidence how the home is meeting one service users cultural dietary requirements. There is no suggestion that these needs are being overlooked, as the needs are known but there is no positive evidence of how they are being met. Food stocks are plentiful, service users have a pleasant dining area and service users who are interested are involved in food preparation and table setting Station House DS0000020580.V294732.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): 18, 19, 20. Quality in this outcome area is generally good. Service users receive routine health screening and specific health interventions to meet their individual needs. Whilst the management of medication is generally good, improvement is required in respect of systems to support both the administration of short courses of medications and those prescribed ‘as required’. This will ensure service users health is fully promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans provide good personal care guidance to staff to enable service users needs to be affectively met in the way that they prefer. Sight of care plans and discussion with staff illustrate that the value of service users independence is recognised and promoted. Finance records evidence regular visits to the hairdressers. All service users present as very well groomed. Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 17 From assessing the care provided to two service users, it was evident that service users receive routine health screening and medical attention to meet changing and or specific health needs. Medication is also regularly reviewed with medical practitioners. From observation of telephone calls, the Inspector was satisfied that service users benefit from the home’s good working relationships with partner health professionals. Since inspection two Doctors have sent two very positive comments about the service provided at Station House to CSCI. One reads as I am ‘‘VERY impressed with the quality of care and knowledge and attitude of staff towards clients’. Long-term medications are managed acceptably, with good records, good storage and administered only by trained staff. Changes to medical direction for the administration of medication could be accounted for. Assessment of practice in respect of the administration and recording of prescribed short courses of medications e.g. antibiotics illustrates the need for improvement through a review of systems. A protocol based upon written medical direction is required for the administration of medication prescribed as ‘as required’. This will protect service users from the potential risk of the overuse of medication although there was no evidence of this, at inspection. Following this feedback, the Manager acted immediately by telephoning the Consultant Psychiatrist to make this request. Inspection of Medication records showed that antibiotics prescribed in December had not been administered as directed and 22 signatures for 21 tablets questions the integrity of the Medication Administration Record on this occasion. The Inspector discussed this with the Manager highlighting the need to identify, investigate and act upon such omissions. Developing an audit of Medication records and a system where staff respond to gaps in records will ensure that service users medical welfare is better supported. Medications ordered monthly are checked and recorded onto the premises. This short course of antibiotics had been prescribed and received into the home mid medication cycle and consequently had not been checked, verified and recorded in to the premises reducing the home’s accountability and ability to audit medication practice. The Manager responded positively to this feedback and resolved to ensure that the necessary improvements are implemented. Station House DS0000020580.V294732.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): 22, 23. Quality in this outcome area is good. The Manager has responded positively and with concern to a received complaint, which appears to have been resolved. Current policy, procedure, practice and staff understanding all contribute to protect service users well. Staff training has been provided but the need for improved training has been identified and booked. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager proactively manages complaints. Appropriate guidance is available for service users and visitors. Relatives who visit infrequently due to infirmity and geographical distance have been sent copies of the complaints procedures, the Manager said. A complaints log is available which shows the home has received one recorded complaint (in July 2006) from a neighbour via Environmental Health about noise in relation to one incident following the admission of a new service user. The Manager was concerned to receive this complaint as she values positive relationships with the local community. There is documentary evidence that the complaint was investigated and that the complainant was responded to verbally. There has been no further contact and the Manager believes the issue to have been resolved. Staff meeting minutes and discussion with the Manager indicate that the incident leading to the complaint could have been avoided had the home received specific information relating to a service user Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 19 prior to his admission. The Commission for Social Care Inspection is not aware of any other complaints and none have been made directly to the Commission. There have been no allegations, no adult protection incidents, no service user accidents or any staff disciplinary action. The Manager has identified her own learning needs arising from inexperience in such matters and is booked onto an appropriate course to help her to manage the referral process in the event of an incident or concern. This is appropriate but the Manager would be further assisted in the event as the home holds all appropriate Policies and procedures to guide her. All staff with the exception of a new staff member have done adult protection training and it is booked for the new staff member. Discussion with a new and a long-term staff member shows good understanding of what abuse is and their roles in the event of any concern. Staff are trained in physical intervention but the Manager has identified the need for improved training which is booked for all staff. Care plans appropriately guide any physical intervention / restraint based upon the principle of last resort. There have been three restraints since the last inspection following the admission of a new service user. These were not reported under regulation 37 to CSCI but are appropriately documented within the home. It wasn’t possible to inspect all aspects of the financial management of service user monies as monies are received by Head office from appointees. However systems are in place to account for monies received onto the home premises from head office. Records of receipt, expenditure, reason for financial activity and balance are all maintained. Spending appeared appropriate and cash in hand tallied appropriately with records for one service user whose accounts were inspected. Discussion showed a staff member to believe that service users are safe at Station House and well protected. Station House DS0000020580.V294732.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): 24, 30. Quality in this outcome area is very good. Station House provides service users with an attractive, comfortable and well maintained, safe home that meet their individual and collective current needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Station House is homely, domestic in size and style, clean, well maintained and safely meets service users current needs. The Manager said that the organisation provides adequate support and resources to maintain the premises with no undue restrictions. Radiators being low surface temperatures are safe, water temperatures are safe and are regularly monitored, cold food storage systems are in place, there are no odours and no laundering on the premises. Windows are restricted and ground floor glass is safety glass. Steps have been taken to further improve Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 21 safety where the need has been identified e.g. stair railings have been raised and bedrooms are not lockable based on assessed risk. All sampled service documentation was available and up to date assuring that the premises are inspected and certified to be as safe as possible. Wardrobes however are not restricted and are not risk assessed. This was discussed with the Manager. A` requirement to assess the level of this risk has been made under Standard 42. Service users due to the nature of their disability were unable to tell the Inspector about the home. However one service user said he was ‘Comfortable’. Laundering does not take place on the premises. The Manager and Inspector discussed whether this inhibits service users from taking some responsibility for their laundry and learning new skills but the manager felt that this is not an issue currently. She said thought that it is something she is aware of and will keep under review. Station House DS0000020580.V294732.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): 32, 34, 35, 36. Quality in this outcome area is generally good although there are some shortfalls. The staff team is experienced, motivated, well trained and feels supported. This enables them to meet service users needs. However, there is not a sufficiently developed infrastructure to support the team should the staffing complement change. This does not maximise opportunities to ensure ongoing staff competency. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Recruitment records for the only new staff member were not on site. The Manager provided copies to CSCI following inspection and prior to writing this report. Discussion at the time of inspection with the new staff member concerned confirmed that two references had been sent for and that he had been unable to commence in employment prior to receipt of a Criminal Record Bureau check ensuring the suitability in advance of staff to work with vulnerable adults for their protection. Records provided show good Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 23 recruitment practice but any gaps in the applicant’s employment history must be more fully explored and recorded. A good training programme is in place that helps the effective planning of training for all staff. Where there are omissions in training these have been identified and are booked. For example seven courses are booked for a new staff member for the month of January 2007. He verbally confirmed the plan. The team has exceeded the national target for obtaining qualifications to NVQ level 2 and are to be commended for this. In discussion with the Inspector on the phone the independent individual who undertakes Regulation 26 visits spoke highly of the training programme available to staff. This supports staff to work competently and to meet the needs of service users. Staff present as happy and motivated. A new staff member spoke highly of the ‘experienced’ staff team and the Manager saying he had been given lots of advice and support and had been helped to settle in well. An independent visitor who conducts Regulation 26 visits monthly to check standards of care spoke highly to the Inspector of the staff approach with service users, commenting in addition on how the staff team is mutually supportive. Staffing levels are appropriate and are provided flexibly. Evidence of staff meetings was not available at the time of inspection as they were held on a broken computer. A staff member however said they take place. Detailed minutes of monthly staff meetings, which are service user focussed, have been provided to CSCI following inspection but prior to the time of writing this report. Two areas were identified for improvement. Previous improvements to the formal supervision of staff have not been maintained. The Manager needs to review the systems which underpin the provision of supervision to bring about improvements in the frequency and style / content of supervision through possible delegation, planning in advance and training in supervision skills including the role and function of supervision. A new staff member has not received formal supervision in the first two months of employment; second and third staff members have received two supervisions in 11 months. A minimum of 6 must be provided. Positively however, staff had had performance appraisals in February 2006. An in house induction system is in place with a health and safety emphasis. This could not be inspected for a new staff member as it was not on the premises but was seen for a further staff member. Discussion showed that an induction system is not in place to ensure that new unqualified care staff are inducted to the national standard to ensure they have basic essential knowledge to meet service user need and effectively carry out their role. This has reduced the overall score attributed by CSCI for an otherwise good staff Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 24 training programme and a new requirement has been issued to ensure that this situation is addressed. Station House DS0000020580.V294732.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): 37, 39, 42. Quality in this outcome area is good. Service users benefit from an enthusiastic and capable manager who ensures that their needs are met and that their health and safety is promoted as far as is possible. A review of and improvement to quality assurance systems will support the homes ongoing development. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Manager is registered with CSCI and is appropriately qualified. She has undertaken ongoing training in 2006 to update her knowledge and skills with more planned for 2007. She feels well supported and stated she is now receiving regular, monthly supervision by an independent person appointed by the company who is also undertaking regulation 26 visits. Records to evidence Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 26 the manager’s supervision were not available on site but the visitor book evidences monthly and twice monthly visits by the person appointed. Regulation 26 records were available. The Manager acknowledged the need for training in supervision skills including developing an understanding of its role and function. Staff spoke highly of the Managers approach with one staff member describing it as ‘very good’. The Inspector was told that the Manager ‘works hard, is very approachable, makes everyone happy and is fair but kind of strict’. There is some evidence of the home having a Quality Assurance system and an improvement in regulation 26 visits forms part of this. The Inspector was shown one completed relative questionnaire for 2004 and one for 2005. Those sent out and returned in 2006 prior to the last inspection were not available and although the Manager felt she had recorded the analysis of the responses, this could not be located and was therefore not available. The views of third parties have not been sought about the service provided. Quality assurance systems are in place for some aspects of the service such as health and safety but systems are disparate and self-assessment systems are not in place for all aspects of service provision. The Inspector sampled a range of service maintenance documents and all were found to be available and up to date ensuring that service users benefit from a well maintained and subsequently safe environment. The Fire Service last visited the home in September 2005 making no recommendations for improvement and the Health and Safety Department last carried out a visit in May 2006. Safety glass has been fitted on the ground floor to meet the needs of a service user to better assure safety. Station House DS0000020580.V294732.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 X 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 3 23 3 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 3 34 2 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 2 X X 3 X Station House DS0000020580.V294732.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 YA17 Regulation 17(2) Sch 4 13) Requirement The Registered Manager must ensure that; Records of the food provided for service users are in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise (e.g. cultural), and of any special diets prepared for individual service users. New requirement January 2007. Timescale for action 28/02/07 2 YA20 13(2) 31/01/07 The Registered Manager must make arrangements to ensure that all medications received into the home are appropriately checked and recorded in (including any medications received mid medication ordering cycle) The Registered Manager must review systems to ensure that all medication is administered as prescribed and that the integrity of the MAR charts in this respect accurately represent Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 29 administration practice. The Registered Manager must implement an evidenced system whereby she regularly audits the medication records and acts upon any discrepancies. The Registered Manager must ensure that written medical direction for medication prescribed as ‘as required’ is received and that safe systems for its administration are developed. New requirement January 2007. 3 YA34 19 Sch 2 During the pre employment of new staff the Manager must ensure that a satisfactory written explanation of any gaps in employment are obtained. New requirement January 2007. 31/01/07 4 YA35 18 The Registered Provider must Review current induction training For new staff to ensure that the home is providing structured induction training to the required National Minimum Standard. New requirement January 2007. 30/06/07 5 YA36 18(2)(a) The registered person shall ensure that persons working at the care home are appropriately supervised at least 6 times per year. New requirement January 2007. 31/01/08 6 YA39 24 The registered person shall establish and maintain a system for evaluating the quality of the services provided at the care home. New requirement January 2007. 30/06/07 7 YA41 37 The registered person shall give notice to the Commission DS0000020580.V294732.R01.S.doc 31/01/07 Station House Version 5.2 Page 30 without delay of the occurrence of any event in the care home which adversely affects the wellbeing or safety of any service user. (This includes notifications of any restraint employed) New requirement January 2007. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Station House DS0000020580.V294732.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Station House DS0000020580.V294732.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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