Inspection on 14/07/08 for Stepping Stones

This inspection was carried out on 14th July 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Stepping Stones 04/08/07

Stepping Stones 17/10/06

Stepping Stones 19/02/06

Stepping Stones 06/09/05

Stepping Stones 11/01/05

Stepping Stones 20/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Stepping Stones Broadoak Newnham-on-Severn Gloucestershire GL14 1JF Lead Inspector Mr Tim Cotterell Unannounced Inspection 14 /15 and 17th July 2008 10:00 th th Stepping Stones DS0000016589.V360738.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 Stepping Stones DS0000016589.V360738.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. Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stepping Stones Address Broadoak Newnham-on-Severn Gloucestershire GL14 1JF 01452 760304 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) Stepping Stones Resettlement Unit Limited Mr Nigel John Greenhalgh Care Home 33 Category(ies) of Learning disability (33), Sensory impairment (1) registration, with number of places Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Sensory Impairment category applies to one (1) named service user only. Category to be removed when service user leaves the home. 4th August 2007 Date of last inspection Brief Description of the Service: Stepping Stones is a registered care home for 33 adults with a learning disability who may also exhibit challenging behaviour. Accommodation is provided in 7 small units. Each unit accommodates between 3 and 7 service users. There are further developments planned in the long term to provide self-contained accommodation for up to 6 people. The home is set in extensive grounds, which includes a horticultural area, an aviary and a swimming pool. There is also a day centre on site which is staffed separately. It is attended by service users from Stepping Stones and also from other homes in the Stepping Stones group. Stepping Stones Resettlement Unit Ltd has recently retained its ISO 9002 award. Copies of the last inspection report are available in the home. The current fees of the home are from £1400-to £2450 per week. Stepping Stones DS0000016589.V360738.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 this service is 1 star. This means the people who use this service experience adequate quality outcomes The home is managed by a new manager who was appointed in May 2008. Stepping Stones has made a formal application to us for him to be registered as the registered manager. The acting manager was available throughout the inspection and provided all of the information we required. The inspection was undertaken over three days the first two being the full day and the third a half day. On the first two full day two inspectors were involved on the last half-day one inspector. The inspection consisted at looking at the environment and all houses were visited. We saw all communal areas and looked some bedrooms taking a random sample. We received completed surveys from resident’s, staff and relatives and their comments are included in the respective sections of this report. We also spoke to a the majority of residents, the Chief Executive, acting manager, clinical psychologist, quality assurance and human resources manager and the majority of staff who were on duty. A consultant psychiatrist was also visiting and we took the opportunity of talking to him. We also looked at records and they included care plans, health care records, medication, recruitment and personal monies. What the service does well: The home provides support to staff from a range of professionals who are based on the campus e.g., clinical psychologist, behavioural therapist, ,deputy manager and manager and human resources staff. The home has clear records of the assessed needs of the residents, up to date and comprehensive plans of care together with good records of healthcare received. Care staff were seen by us to have a good relationship with residents and were seen as patient and good listeners, Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 6 Residents have a range of activities and this has recently been extended to ensure the changing needs are met. What has improved since the last inspection? What they could do better: 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. Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 7 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 Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 8 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. This judgement has been made using available evidence including a visit to this service. New residents are only admitted after a full assessment that includes professionals who know and understand their needs. Independent advocates are used to help protect residents’ rights and ensure their wishes are taken into consideration prior to admission. EVIDENCE: We looked at a pre-admission assessment for a new resident, which had been completed two months prior to admission by the registered manager and the homes newly appointed clinical psychologist. The records included a detailed assessment from the Community Learning Disability Team (CLDT) prior to admission, which was an excellent record containing a lot of detail about what had been happening and what was working and not working to help the resident. The psychiatrist had also contributed to the assessment process. The manager told us that residents usually look around the home and stay for lunch, then have an overnight stay before they are admitted. Emergency admissions sometimes occur when a placement has broken down elsewhere. There was also a record of the support from an Independent Mental Capacity Advocate (IMCA) for the resident with regard to helping him make the decision Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 9 to move from the care home where his challenging behaviour was presenting a problem. Cultural and faith needs had been identified to help ensure that this could be continued after the move to Stepping Stones. It was evident that the residents preferred activities were highlighted and personal preferences to enable future support and wellbeing to continue. With this prior information a detailed risk assessment had been completed on the day the resident arrived at Stepping Stones. There were clear indications of behaviour observations to alert staff to any deterioration and potential challenging behaviour, which included instructions to help staff manage this, for example distraction and de-escalation techniques. The strategies were clear for each identified risk, which included the environment, physical health, mental health, behaviour and when out in the community. The support required was identified as one to one daily and two staff to one when out in the community. We spoke to the resident who had been at the home for three weeks and he was pleased that he could still visit his local church every Sunday with two staff, but still needed time to feel settled. Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The care plans identify what support strategies are required to help residents to reach their full potential and become as independent as possible. Residents are involved in setting their own goals and are supported to learn new life skills. There needs to be sufficient staff to support residents at all times in a dignified manner, and some staff need to learn the skills that will help to promote independence and wellbeing. Risk assessments are very well recorded and the strategies recorded with the help of professional staff at the home help the care staff to manage challenging behaviours and improve outcomes for all residents. EVIDENCE: Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 11 We looked at four care plans, three of them in detail and spoke to the four people about their care and support. Many residents have complex needs, most have a learning disability, but there are many with mental health and personality problems including psychosis and bi-polar disorder. This requires the support of health and social care professionals, which includes the Community Learning Disability Team (CLDT) and referrals are made to them, which helps to ensure staff have continuing professional advice when required. Care plans have good pictorial information about what people like doing and their goals, how they see themselves, how others see them and what they don’t like. One resident’s plan stated that they hoped to get a job, which has yet to be achieved. There are ‘Pathways to Independence’ records, which are regularly reviewed and a tick list is used for what has been achieved already, and any progress is monitored. There are skills development plans that included the following areas for one resident; 1.Meaningful activities – The preferred activities were recorded on an evaluation sheet daily, and there were good records of what is achieved or not. This resident had not attempted activities for 3 days and the reason recorded was ‘would not get up’. However, no reason was recorded on why this resident did not want to get up. 2. Relationships – There was a protocol for the resident and her partner, also a resident at the home to spend time together in their bedrooms, which took into consideration the other residents. This resident was about to start a ten week course about relationships and it was hoped this would help with communication. A ‘Best Interests’ record had been completed to ensure that both parties were able to consent to a sexual relationship. 3. Independence –This plan included staff support with cigarettes and who would be responsible for the cigarette lighter. There were good detailed daily records of mood, activities, food, and a ‘whereabouts’ chart was maintained so that staff regularly check that a resident is still on campus when absconding is a problem. This includes checking the activity centre. A description is kept of all residents should they go missing from the home. The ‘acute issue’ records seen were detailed, and staff told us that they record every incident considered to be a problem. The homes cognitive behaviour therapist looks at the records and talks to staff if she thinks she can help to improve how the staff are managing the incidents. A bar chart is produced of all acute incidents for each resident as an aid to reviewing their progress. The well recorded monthly reviews identified, trips out, behaviour issues, meeting family and how many days the activity timetable was followed. The last risk assessment for this resident identified some medium to high level risks with fire, sharps, absconding, and aggressive behaviour, which had detailed strategies recorded for staff to follow. Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 12 After a psychological assessment in November 2007 the resident attended eight anger management sessions to help with aggression. The resident was going on holiday the day following our inspection and the team leader had not finished completing the risk assessment. The team leader was very busy and seemed to have little time to complete such an important assessment. We spoke to the resident who had many concerns, which were of a psychological nature and was unhappy living in the home and was absconding weekly. The resident knew about her care plan and had helped with her likes and dislikes. We observed her enjoying activities in the music room where residents were playing musical instruments. A review was planned for the following day to include everyone involved with the resident and her mother to look at the way forward. We saw a second care plan that had good detailed records, objectives for personal development were well recorded and included strategies to encourage progress. However, one daily objective, helping with meals, had only been achieved six times in a month, which may require additional strategies for progress to be made. We saw that the daily evaluation sheet had been completed that identified where improvements could be made. The risk assessment gave clear guidelines and identified the level of risk. Daily records were informative and helpful for the staff where mood changes were recognised and increased support may be needed. We spoke to this resident who was unhappy and wanted to leave the home and said that the staff did not make conversation. We spoke to the resident’s key worker who although supportive did not appear to communicate well with the resident, and may benefit from additional training. A review had been requested with the placing authority, the meeting was to be held the following week. A third care plan seen was well recorded, however, the resident had physical health problems and was currently unwell and in pain. The daily records said the night was unsettled and pain relief was given. We spoke to the resident who obviously required additional pain relief and the staff informed the doctor immediately. A more effective analgesia was prescribed for palliative care and during the inspection the new medication was collected and the need to inform the district nurse and possibly the Macmillan nurses was discussed with the staff. There were another two highly dependant residents in this unit and only one care staff who was finding it difficult to meet all three residents needs, and had requested help to take an injured resident to the toilet. The resident had to wait while staff were located, which was inappropriate and undignified. We spoke to the new clinical psychologist who was advising staff about strategies in care plans and had regular face to face discussions with some residents. We spoke to the visiting psychiatrist who was in regular contact with the home when referrals are made to the CLDT. Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate and individual lifestyles are more likely to be achieved when there are adequate staff on duty. Staff ensure that links are maintained between resident and families and were seen to provide support to both parties. Healthy diets based on menus will only be provided when the food is available and staff follow instructions EVIDENCE: Stepping Stones provide activities on the campus and have recently extended the opportunities for the residents. We visited the “music room” and saw five residents engaged in singing and playing instruments, it was clear that they were enjoying the exercise which was managed well by the support worker. We also spoke to the new “cookery” support worker who was introducing Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 14 cooking skills as an additional activity. Many comments from staff and residents referred to the lack of activities in the evenings and at weekends. One resident had a skills development programme and one of the objectives was that he would have a daily activity ideally outside the campus; the activity would in view of his dependency require one member of staff. The records in the house indicated that there were only four occasions in June when this was achieved. We were informed that there was insufficient staff on duty to undertake this activity. We were informed that many of the residents have good links with families and friends and we were able to see a relative during the inspection. The relative who was seen said they felt able to visit at any time and found the staff helpful and always prepared to listen. We received completed surveys from five relatives and the comments from them included, “the care is excellent”, “happy with the care”, “everything is good” “my son is happy and relaxed”. One said that the high staff turnover and use of agency staff results in some staff not knowing what they were doing and whilst staff in charge are competent some staff lack experience. We saw many interactions between staff and residents and felt that the resident’s rights were respected and that they were treated as individuals with varying levels of understanding, which was reflected in the appropriate staff responses. However we felt that one carer needed more guidance about how they dealt with residents and this concern was passed to the manager. We were told that not all of the resident’s clothes were labelled and that this could result in residents wearing the wrong clothes. Six residents surveys were completed and returned, two would like more say in what they do, two others said they were happy in the home. Two said that they did not like living in the home but would speak to senior staff regarding this and did not want the inspector to approach them direct. One resident said that they wanted to speak to an inspector and this was arranged during the inspection. We saw the six week cycle menus, which had been compiled after the home took professional advice. During the inspection we noted that two of the houses were unable to provide the main meal indicated on the menu as they did not have the correct ingredients. This could have been due to staff ignoring the menus or alternatively not having the ingredients. In either case if menus are not followed it could affect any attempt to provide a healthy and balanced diet. This issue was raised in the last random inspection (March 2008) Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the healthcare support they need and audits are completed to aid quality assurance and help ensure medication continues to be managed well. The medication records are well maintained and staff are trained to administer medication safely, reducing any risk to residents. EVIDENCE: Personal care is provided in a sensitive manner for people with healthcare needs, however to ensure dignity is maintained at all times staffing levels must be reviewed. Times for getting up and going to bed are flexible but often mean staff are supporting well into the early hours for some people, which means there must be enough resources to ensure all residents are well cared for. Each resident has a personal healthcare record, which the deputy manager, who is a registered nurse learning disabilities, helps to ensure is kept under Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 16 review and updated as required. The deputy manager was unavailable during this inspection but we looked at three healthcare records. The healthcare records seen were very good and contained detailed information about any healthcare professional support or hospital appointments, including the results of blood test etc. Any minor health problems are followed up to help ensure that serious health risks are prevented. The healthcare records included a good pictorial self-assessment. Female residents have regular cervical smear tests and contraceptive advice and support is given, which includes consent forms that are kept in the main office to protect resident’s confidentiality. There is separate record for staff to use should any residents be taken to hospital in an emergency to help ensure that all medical information is given. Residents have regular chiropody, dental care, optical checks and specialist support from healthcare professionals, for example, district nurse. occupational therapist, speech and language therapist, and continence adviser. Weight charts are maintained and residents are supported and advised to help maintain a health weight. Epilepsy care plans and seizure charts are maintained to monitor their frequency and provide information for the doctor regarding appropriate medication control. We saw some good healthcare summaries, which are recorded every six months and include regular reviews by the CLDT when required. The district nurses were supporting one resident that had a pressure ulcer that had almost healed. There were clear records where a resident was supported by the home during treatment for an illness and was waiting for another review. Daily records were clear about how this resident was and a deterioration was noticed on the day of the inspection. Medication in the home is managed well; we looked at one house in detail, one bungalow and additional central medication storage. Both units had a good medication procedure, which included a ‘homely remedy’ procedure for medication not prescribed. Doctors have signed and agreed what medication ‘‘ the staff as a ‘homely remedy’ can give. There was a medication reference but it was recommended that the home regularly obtain a British National Formulary book from the surgery for up to date reference. We looked at the homes monthly medication audits, which were not always completed. Residents had recently been given a questionnaire about medication, which the home can use for quality assurance purposes. There were good records for recording medication into the home and returns to the pharmacy. The administration records were well recorded and any medication omissions are recorded and signed, which is good practice. We completed a spot check of medication and amounts were correct. A gel prescribed for wart treatment Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 17 should be recorded on the medication administration chart. One transcribed medication record had an abbreviation of the medication recorded this must always be written in full to avoid confusion. Each resident has a clear medication risk assessment in pictorial form and individual procedures about how their medication should be given. Medication reviews are completed regularly. We looked at several good individual protocols for ‘as required’ medication, however, some need to state how many doses can be given as a maximum before the doctor is informed. There was a good protocol for ‘as required’ buccal midazolam to be given for a seizure, and a good Purcutaneous Endoscopic Gastrostomy (PEG) feed procedure and risk assessment seen. Staff spoken to knew what to do when the resident had a seizure and were confident administering the PEG feeds. The deputy manager trains all staff to administer medication. We looked at the booklet they must complete and the shadowing sheets completed to ensure the staff are competent. All staff have an annual refresher in medication training. The new acting manager has made good progress ensuring more staff have medication training, including the night staff. Stepping Stones DS0000016589.V360738.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 adequate. This judgement has been made using available evidence including a visit to this service. The current procedure could be more user friendly and alternative methods to convey the procedure could be considered. Staff were seen to be good listeners and where problems occur there is a genuine and concerted effort to resolve the matter. Vulnerable residents may need additional staff to ensure their safety and wellbeing. Staff would benefit from updating in training in respect of the identification of abuse. EVIDENCE: We looked at the home’s policy and noted that it included symbols in an attempt to assist the reader to understand what was being said. It is recommended that the procedure is further reviewed in an attempt to help as many residents as possible understand that they are able to complain and the methods used. The “complaints “ file was seen and there had been nine complaints recorded. The record indicated that the home had investigated the matters and where appropriate the respective correspondence was attached. It is recommended Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 19 that all complainants receive a written response from the home. At the time of the inspection the home was investigating an anonymous complaint about the care practices and enquiries were being made in an attempt to identify the house and staff who were the subject of the allegations. The home also intends to record all concerns. Three sets of financial records in respect of resident’s personal allowances were seen and found to be correct One resident had a care programme, which indicated to staff that their response to any inappropriate behaviours should be “a low arousal approach” and an example of this response was seen during the inspection. Whilst staff should be commended for being aware of and complying with the response the outcome for other residents who were in the house seems less than satisfactory and resulted in them leaving the house as they said they were afraid. One of the residents had telephoned their parent to ask if they could help as the disruptive behaviour of one resident was causing considerable distress and a threat to self-harm by another resident if the behaviour continues. Another example occurred when an inspector was sitting in one of the houses and a resident who was agitated came in and was shouting and swearing and banging the locked kitchen door. No staff were in the house at this time. This situation does not seem appropriate, but we were told that staff often lock the kitchen door at teatime ro prevent residents entering and sometimes disrupting the preparation of tea. That could be appropriate where this is someone else in the communal areas. Between 3 April 2008 and 25 June 2008 we received twenty-four Regulation 37 notices the majority of which referred to incidents where challenging behaviours had resulted in some disruption for other residents. In a number of cases staff and residents had been abused and assaulted. The acting manager was asked to look carefully at all “critical incidents” in an attempt to identify causes and hopefully find ways of reducing the frequency of these events. Stepping Stones DS0000016589.V360738.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 adequate. This judgement has been made using available evidence including a visit to this service. Whilst there is a continual programme of refurbishment some carpets and furniture require cleaning/replacing. Worn mattresses provide little comfort/support and all mattresses should be examined to ensure that those that are worn are replaced EVIDENCE: We were shown around the houses by the manager and staff. The bungalows were in good decorative order and had appropriate furniture although in Rose Lawn one of the settees has no fitted legs and may prove more difficult for the residents to use. Cedar Falls House Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 21 was having new carpets fitted in the lounge/dining areas. Elmlake The lounge/diner carpet was stained and should be professionally cleaned or replaced. Two bedrooms were seen and had been personalised. The glass in the back kitchen door had been smashed several days before the inspection but was not replaced until Tuesday 15 July 2008. During this period the broken glass remained in the frame and whilst covered was easily accessible and was seen by us as a potential danger to the residents. It is recommended that glass replacements should be undertaken without delay to prevent accidents. Pinebrook A new wooden floor had been fitted in the lounge/dining area. Two bedrooms were seen and they reflected the interest of the resident. Poplars View The carpet in the lounge was badly stained and must be cleaned or replaced. Some of the lounge furniture was damaged and should be replaced. Three bedrooms were seen and further attempts should be made to personalise the rooms although it is appreciated that efforts have been made previously. In one bedroom the mattress was worn and offered little support this should be replaced. We did not determine the fitness of other mattresses and recommend that all of the mattresses are inspected to ensure they are fit for their purpose. The campus has extensive grounds to include a vegetable garden managed by the residents and the well-kept and level areas provide a pleasant alternative for the residents. All of the houses/bungalows were clean and odour free Stepping Stones DS0000016589.V360738.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The good work of staff will be supported and reinforced if the organisation ensure there are sufficient numbers on duty. The protection of residents would be improved if the recruitment procedures were subject to a more rigorous check. EVIDENCE: During the inspection we spoke to the majority of care staff who were on duty and it was evident that they were anxious to provide a caring and flexible service that responded to individual needs. However the current staffing levels are clearly preventing staff from achieving this. We witnessed inappropriate behaviours in one house where a number of residents were disturbed by the behaviour of one resident. During this disturbance two residents left the house as they said they felt unsafe. We were told that there are usually two care Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 23 staff on duty however where the second person was a team leader it was probable that he/she may have to leave to undertake other duties ,this leaves one member of care staff to supervise the group. In another case the plan of care included an objective that one resident would go out each day supervised by a member of staff as the resident is not involved in the activities provided. The records in the house indicated that it had only been achieved once in June. In this house there are usually two care staff on duty. To provide the activities for one person who was said to require one to one when out would mean having three staff on duty. We were told that up to 0900 and after 1700 a team leader supervises the campus. The team leader is also on duty in one house during the day as part of the supervisory team. During a shift we were told that the team leader might have to leave the house for a range of other duties e.g. administration of medicines, meetings and to deal with problems, which may occur. This would leave the house with one member of staff and this is seen as unsatisfactory and could place residents and staff at risk. At weekends when they are no supervised activities the staffing ratio remains the same. We were also told that some residents required one to one supervision on campus, which was confirmed by the records in the home. However this classification was later amended as the manager told us that all residents are reassessed when they are admitted and at the time of the inspection there were no residents who required this level of supervision. Clearly there is contradiction over this matter (see page 10, last paragraph of this report) and you will appreciate that it is essential that the supervision levels of residents are determined and reviewed and that the respective levels are maintained. There were five waking night staff on duty on the main campus and one of the night staff has responsibility for two houses. We were told that until recently access to house one and two was made possible by leaving a fire door open on the first floor. We discussed this with the manager and pointed out the potential dangers of doing this and we understand the practice has stopped. To ensure night staff carry out their duties as required the home must ensure they are instructed on what is required, with particular reference to the waking staff responsible for the two homes e.g., the frequency and purpose of the visit. We looked at a sample of staff records and inspected the last two appointments. A human resources manager manages the systems but there is also some work undertaken at another site of Stepping Stones Resettlement Co. In one case in spite of the guidance to applicants, references had been received from what could be considered as family (partner and partner’s parent). In another case there was no “personal references” and there was no recorded attempt to determine why this had not been forthcoming. We would Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 24 also draw you attention to the current Regulation, which refers to the need to take up additional references from previous employment in homes, which accommodates vulnerable people. A sample of the interview notes were seen. Stepping Stones DS0000016589.V360738.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 adequate. This judgement has been made using available evidence including a visit to this service. The needs of some residents are not being met due to insufficient staffing levels. Inadequate staffing has and will place residents and staff at risk and the efforts and goodwill of staff may be compromised. Fire doors, which are left open, increase the danger for residents in the event of a fire. The recording of staff meetings will ensure that there is a clear record of issues raised and action taken in the respective houses. EVIDENCE: Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 26 Since the last inspection the registered manager has been appointed as Commissioning Manager and the new manager was present at this inspection. An application has been made to the Commission to register him and he now is waiting for a date for an interview at Bristol. The new manager who commenced work at the home in May has already identified a number of areas he wishes to improve/review. During the inspection we had direct evidence of the inadequate levels of staffing and the consequences arising from this. This aspect is raised more specifically under “concerns, complaints and protection” and “staffing”. However it is a matter, which rests with the management of the home. The health and safety matters are dealt with by a dedicated member of staff and the assessment on the properties are reviewed annually. We were informed that to provide adequate supervision at night one first floor corridor door between the houses had been left open. This practice must cease as it places residents at greater risk in the event of a fire. If the home requires relaxations of “the closed fire door policy” it must consult with the Fire and Rescue Services. The manager has support from the company through the Clinical Director who provided supervision. The manager is responsible for care staff and delegates some of the duties to three team leaders Staff are required to complete a “critical incident report” however we were not clear about what constitutes a critical event and it is recommended that the registered person defines the term in a practical sense to ensure staff are clear about their expectations The last Regulation 26 visit report was seen and dated April 2008. Regulation 26 visits are required to be undertaken monthly and the criteria for those carrying out the visits are expressed in the Regulation. The template used by the organisation included medication and care planning and it is essential that the person undertaking the visit is competent to comment on all of the issues on the template. It is recommended that all staff are updated in the “identification of abuse” We were informed that the “houses” have regular meetings for staff and residents however recent records were not available and we were given a copy of a “house meeting” dated 28 July 2007. The meetings should be recorded and written in a manner which ensures the issues are clear. If the meetings are not always recorded it may mean that issues are lost and matters not acted upon by the next level of management. Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 27 The manager meets the three team leaders weekly and we attended one of the meetings. It was felt that the manager provided leadership and clear guidelines for the team leaders. It is recommended that a record is kept of the meetings. The format for the supervision of staff has been revised and the new format will now be introduced. Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 28 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 X 34 2 35 X 36 x 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 3 13 3 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 2 x Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 29 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. 2. Standard YA42 YA24 Regulation 23 23 Requirement The registered person must ensure that all fire doors are kept closed The registered person must undertake the repairs/cleaning/ replacement of furniture/carpets/mattresses as identified in this report. The registered person must ensure that there are sufficient staff on duty to meet the needs of the residents. The registered person must have a robust recruitment procedure Timescale for action 17/07/08 30/09/08 3 YA33 18 17/07/08 4 YA34 18 17/07/08 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. 2. Refer to Standard YA19 YA19 Good Practice Recommendations Undertake a monthly audit for medication and add a time limit to the homely medicines procedure. Ensure there is a British National Formula available in all houses. DS0000016589.V360738.R01.S.doc Version 5.2 Page 30 Stepping Stones Stepping Stones DS0000016589.V360738.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Stepping Stones DS0000016589.V360738.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. 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