Inspection on 02/03/06 for Strafford House

This inspection was carried out on 2nd March 2006.

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

Other inspections for this house

Strafford House 01/08/06

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Strafford House Off Doncaster Road Hooton Roberts Rotherham South Yorkshire S65 4PF Lead Inspector Ms Stephanie Kenning Unannounced Inspection 2nd March 2006 10:20 Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 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 Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 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. Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Strafford House Address Off Doncaster Road Hooton Roberts Rotherham South Yorkshire S65 4PF 01709 855796 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) Voyage Limited Post Vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One specific service user under the age of 18, named on variation dated 26th January 2006 may reside at the home. No previous inspection. Date of last inspection Brief Description of the Service: Strafford House is a care home for up to six adults aged 18 to 65 with learning disabilities. It is owned by the Voyage Group, that has many care homes in the UK. It is located in a small village near to the town of Rotherham, in a converted building behind the Earl of Strafford public house. There are not many facilities in the village of Hooten Roberts, though there is a bus service to Rotherham and to Doncaster. The home overlooks farmland and has its own private garden. Each of the 6 service user rooms is spacious and has an ensuite bathroom. They are located on the first and second floors of the house. There is a communal lounge, a large kitchen dining room and a games room. A small laundry room is available for service users if appropriate. The home was registered in August 2005 and was finished to a high standard. Since registration 3 male and 2 female residents, all under the age of 33, occupy 5 of the rooms. A new manager has just been appointed and will need to be registered with CSCI. A minibus is available for service user transport. Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 3 days, 2nd, 3rd and 7th March 2006 and covered all the key standards, as it was the first inspection of this care home. An original inspection date of the 5th January had to be abandoned due to a problem with a service user. A visit in response to a variation to registration request took place on January 27th 2006, regarding the admission of a service user under the age of 18, and this was granted as they were able to meet the Supplementary Standards for Care Homes Accommodating Young People aged 16 and 17. This inspection also covers those additional standards. The inspection included a tour of the building, checking documentation, case tracking, talking to service users, relatives, visitors and staff, observing interactions between service users and staff, observing mealtimes and medication administration. Over the three days all the service users had an opportunity to talk to the inspector about their experience of Strafford House. Most of the comments were positive, with significant improvements to their lives since residing at Strafford House. The majority of the requirements and recommendations were linked to improving systems and organisation within the home. The new manager had clear ideas about improvements to be made in order to meet the standards. There were a number of Immediate Requirements issued on the 2nd March regarding maintenance of the building and displaying the correct registration certificate, most of which were addressed before the end of the inspection. What the service does well: Service users were generally positive about life at Strafford House, such as their rooms, the communal areas, the garden, the staff, the meals, the type of activities, the contact with family and friends, the support they were getting and their opportunities to contribute to the day to day running of the home. The building, despite some of the problems identified, was bright, modern and attractive, providing a very nice environment to live in. The staff group was well balanced with a number of experienced staff and some from different backgrounds. Staff members were familiar with the needs of service users and presented as very competent. Service users were happy with the way admissions were handled including the trial periods/ visits that allow everyone to get to know each other. Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 6 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. Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 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 Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and supplementary standards 1.1, 1.5, 2.1, and 2.9. Service users have been given opportunities to visit the home before making their decision about where to live, and each had an assessment identifying their needs and aspirations that they felt the home was helping them work towards. EVIDENCE: There is a statement of purpose that has been updated since the condition of registration was applied, showing the services offered at the home. The service user information includes a profile of the home with photographs, and was designed by people at the home. Admissions are planned and potential service users assessed as to their compatibility and whether the home can meet their needs and work with them to meet their aspirations. The person under 18 had a placement plan as required by the supplementary standards. Service users stated that they were involved in the assessment process along with their relatives or advocates, and this helped them to think about where they wanted to live. The potential service users are encouraged to visit to meet other service users, and service users explained how important this was for them when they were looking for a home, and to get on well with new people coming to the home. Despite this process there has been some conflict between service users and some behaviour that has caused them concern. The management of these behaviours has been changed and service users felt that it has improved recently. Specialist services such as, use of a psychologist, have been arranged by the home to assist with the meeting of needs and Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 9 aspirations. Training of staff members in specific topics such as conditions and behavioural management techniques are in progress. Contracts/ terms and conditions were seen in individual service user files and these specify the particular arrangements for living at the home for each individual. Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 and supplementary standards 6.1, 6.11, 6.12, 6.13, 9.1,and 9.5. The service users have identified their needs and goals and have a plan to help them achieve these. There are many areas of their lives that they control themselves, and they were generally very positive about these. EVIDENCE: Each of the service users had a comprehensive plan based on their assessments of needs and aspirations. Although it was stated that they were written in conjunction with service users and their supporters only the staff members seemed to sign them. Plans addressed each area of need identified, and described restrictions linked to risk assessments and gave strategies to deal with situations. Plans were reviewed weekly by key workers and gave good information. The person under 18 has a plan that has been reviewed as required, involved the relevant people, and that was working towards the transition to adulthood. Each file contained a lot of information, but it was difficult to follow through. Separate daily diary sheets were linked to each part of the care/development plan and therefore different parts of the picture were recorded separately. For example when someone was upset or aggressive the record was made in the area for emotional/challenging behaviours, but could affect the other areas such as living /domestic skills or social interaction. Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 11 Nothing was bringing this together, including the triggers for the behaviour or how effective the management of the situation was. It is required that the care planning and recording documentation is reviewed and reorganised so that it is clear to staff supporting the service users, and to enable holistic evaluation and reviews. No recorded audits of care plans were found, and it is required that managers/ senior staff undertake regular audits to ensure accuracy. Service users described many areas where they had made decisions at the home. Some had chosen which room to have and to have different items of furniture. All had personalised their rooms with their choice of belongings, such as television, or bedding, and one person had a pet hamster in their room. They were involved in decisions about meals choices at the weekly meeting, and it was noted that individuals were able to have an alternative at all times. Some people stayed in bed late and were able to follow their own routines, and some service users enjoyed helping to prepare meals for everyone. A recent survey of service users had been held using written questionnaires in which some suggestions for improvements were made and these were going to be discussed at a service user meeting. Records were stored securely and service users were able to access their own whenever they wanted. One service user showed me his file and was familiar with it. He was clear that other service users would not see his file and that staff would treat the information within it confidentially. Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 and supplementary standards. The home provides a supportive base for the development of skills that will enable the service users to be more independent. This new service could develop these lifestyle opportunities further now that it is established, to ensure that service users reach their potential. EVIDENCE: Development plans for each service user show skills development opportunities in social, emotional, communication and independent living skills, so that they can learn practical life skills. Some individuals were following their preferences in education and were settled in these arrangements. One person was in the process of having work experience organised in an area that was his main interest and was looking forward to the challenge. One person had no educational or occupational opportunities at the time due to the lengthy process involved in setting it up, and was understandably bored. The person under 18 had plans for the future, was attending education and had opportunities for personal development. Service users were around a lot during the inspection and had quite a lot of unstructured time. Some people also had a programme of leisure activities and these were very varied from football, Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 13 bowling, swimming, birds of prey, shopping, visits to coast or other tourist attractions, and meals out. It is required that activity plans are reviewed to ensure that they are completed for all service users, that their preferences are correct and that unstructured time is scheduled. Further development of the individuals’ lifestyle opportunities could also be incorporated. Within the home is a games room that has a computer and some board games. Service users wanted additional equipment and this had been discussed and agreed. Service users have been using the facilities of nearby Rotherham for their educational and leisure activities, and for shopping and socialising. They were familiar with public transport links and have the use of the minibus, though they commented that there were insufficient drivers available. Staff members were observed to support service users with their activities in the community. The family and friends of service users visited the home during the inspection and maintaining relationships outside the home was supported where appropriate. Service users felt that their rooms were private and others were only allowed in by invitation. Some locked their rooms all the time, which gave them a feeling of control and independence. Housekeeping tasks were specified in individual plans, and some personal areas were not very clean, such as bathrooms and skirting boards, indicating that more support may be necessary by staff. Meal times were varied with some people eating at different times on one day and then all eating together on another. The weekly service user meeting decides on the choice of food for the main meal of each day with each service user getting their personal choice at least once. Healthy foods were being promoted with a good supply of fresh fruit and vegetables seen, and some healthy snacks as well as less healthy ones. Service users were observed to prepare meals for themselves and for others and with support from development staff. Service users also helped themselves to snacks whenever they wished and had particular stocks of their choice. Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21, and supplementary standards 19.1, 19.6, 19.7. Personal and healthcare support was being offered to individuals who were generally satisfied because their preferences were being upheld. Support to help service users settle in their new home was under -pinning this, and service users did seem to be settled. EVIDENCE: Personal support was provided according to individual plans and service users were generally very satisfied with the support they were getting. All of them felt that the support was developmental and that they were working towards independence. Personal choices were evident, such as times for getting up/ going to bed, but guidance was also available to enable people to make choices about meeting their aspirations. Attention to the emotional needs created by a move to a new home was noted and service users felt that they had settled in well. Specialist support was provided as necessary, for example through a psychologist, and behaviour management techniques have been changed to address some challenging behaviour. Each person has a designated key worker that provides a consistent link to work with the service user. There was evidence that service users were attending health appointments and that they were getting support to do this. One person had an on going health problem that they felt was not being adequately addressed, and this was fed Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 15 back to the manager to deal with. Care workers were aware that they should not smoke in front of the service user that is under 18. Medication was mainly managed by the home, and all the senior staff had certificates in the safe handling of medication. A monitored dose system is used to enhance the safety of service users. The administration charts were being recorded as required and returns to pharmacy were being recorded in duplicate so that a correct record is kept. There is no medication fridge and this is likely to be needed at some point. Other storage was organised and did not contain large stocks or out of date medicines. All service users have a lockable facility within their room in which to store medicines for self administration, and one person was able to self -administer. The supplying pharmacist does not usually visit and inspect their medication administration and storage facilities, and it was recommended that they be invited to do so. There was space for aging, illness and death wishes to be recorded within service user files and development plans and care workers were aware of the sensitive nature of this information gathering. Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23, and supplementary standards. In practice service users seem to be well protected and satisfied, however the recording of complaints is poor and some essential procedures regarding abuse were missing. EVIDENCE: There is a clear complaints procedure available to all service users, and two complaints had been made. The records of these complaints do not show the action taken or the outcome, and this is required. Service users felt able to approach the manager and other staff in order to express their concerns. The minutes of service user meetings were seen and their views and concerns were noted with possible action. Overall service users did feel that their views were listened to and acted upon. There have been no POVA investigations at the home, though neither the adult nor children’s guidance could be found and these would give local instructions to follow if abuse was suspected. It is required that these are obtained and read by each member of staff. There have been some incidents of physical and verbal aggression by service users that have caused other service users some concern. Techniques for managing this have been changed and were making a difference according to both service users and staff. Each of the individual service users monies should be reviewed and a full audit undertaken, as there appears to be complications regarding benefits received and payments needed to be made. For this reason this inspection did not check monies or records. There is secure storage for monies as required. Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30, and supplementary standards. The home is a modern and spacious environment, suitable for the service users who were generally pleased with it. There were a number of serious problems that had developed since opening and these had not been addressed adequately. Most of these were addressed or being worked on before the end of the inspection improving the safety and wellbeing of the people at the home. EVIDENCE: The home was registered in August 2005 and had been completely renovated to a high standard. The premises are suitable for the service user group, with six single rooms all with en-suite bathrooms. Communal areas include a sitting room with door onto the garden, a large dining kitchen, a toilet, a games room and a laundry room. The garden backs on to agricultural land and there is a car park. Each of the six rooms is spacious and exceeds the minimum standard, and each has its own bathroom with bath, toilet and washbasin. There is a mixer shower on each bath. There were some complaints from service users that their bathrooms were very cold, and there was a noticeable difference between the temperatures of the bedrooms and the bathrooms. There was no separate Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 18 heating for the bathrooms installed and this was made an Immediate Requirement to address the problem. None of the baths had shower curtains making it difficult for service users to use their showers without getting the floor wet. The bedrooms are well furnished and very individual due to the personalisation by the service users. Some of the bedrooms/ bathrooms were not well cleaned and service users may need more support with these tasks. One of the bedrooms had a broken door handle that was repaired during the second day of inspection following an Immediate Requirement notice. The second entrance to the home leads into a corridor that was damp with dripping water and water laying in the emergency light fitting. Another Immediate Requirement notice was issued to rectify this and ensure the safety of electrical fittings. The kitchen dining room has a very homely feel and is able to accommodate two large dining tables for when everyone sits down to a meal together. All equipment was working with the exception of the dishwasher that had an electrical problem caused by water from the sink getting into the socket. This was repaired during the inspection. The games room has a computer, craft materials, a keyboard and board games, and was not well used. Service users have requested further equipment such as a pool table and that was being organised. The air conditioning units for this room were repaired during the inspection. Externally there is no light near to the car park and path that leads to the house, and this may prove to be a hazard during darkness or bad weather. The home does not allow smoking inside and service users were seen smoking outside by the entrance. The policy regarding smoking could not be found. Staff members were aware that they could not smoke in front of the service user that is under 18. In the team leaders office there was a hole in the ceiling where wires had been put through and this should be rectified. A number of cracks have appeared as the building has settled and whilst they are superficial they will require attention. The laundry had a damp and fusty smell, and condensation was seen running down the walls near to electrical switches and sockets. The metal frame on the condenser dryer was rusty despite being new on opening the home. An Immediate Requirement notice was issued to rectify this problem and not allow the use of the laundry until it was safe to do so. Stocks of clean linen had been removed from the laundry due to the damp problem. Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 19 The vacant room was being used by the staff on sleeping duty as the designated room was not habitable due to the profound smell of blocked drains coming from the shower tray. The shower was not working in this staff sleeping in room either. Another Immediate Requirement notice was issued to rectify this problem. The certificate of registration did not show the condition of registration applied in January and an Immediate Requirement notice was given, as this was a breach of registration. The new certificate was found and displayed by the end of the inspection. Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36, and supplementary standards. The staff team is not complete and recruitment is needed in order to maintain adequate staffing levels. Those in post were felt to be approachable and supportive by service users. EVIDENCE: The rota showed that three or four staff were on duty plus the manager when there. There is one waking night staff and one sleeping each night. Some service users require specific staff ratios such as 1:1 and this means that staffing levels are not always meeting these requirements. There are some new recruits in the pipeline that need to be started as soon as possible when the recruitment checks are complete. Three staff files were examined and show that the required procedures and checks for recruitment were followed in order to safeguard service users. Some staff had transferred from other homes within the Voyage group and it was difficult to separate the different periods of employment, for example to establish whether supervision records related to the current place of work or previous. It was noted that supervision records were not up to date and that a regular schedule of supervision needs to be established. Individuals had attended a number of training events at Strafford house including Induction, Fire, Abuse, SKIP, Food Hygiene, Health and Safety, Medication, and specific conditions. Some other training needs had been identified and it is Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 21 recommended that the new manager reviews the training needs of each individual and makes a plan for the home for the next year, to ensure that this benefits service users. This review will also identify the numbers of staff with an NVQ in order that they can meet the target of at least 50 of care staff with a Care NVQ 2. The new manager was already looking at roles and responsibilities within the home and deploying the team in the most effective way. Through conversations and observation of staff in their work some very good qualities were seen such as knowledge of the individual service users and communication skills. Service users were complementary regarding the staff and felt that staff were interested in them and were approachable. The atmosphere at the home on each visit was welcoming and friendly with service users and staff being keen to participate in the inspection. Past records of service user and staff meetings were seen and they raise a number of issues that were discussed during the inspection. The new manager was aware of these issues and planned to take them to the impending staff meeting to address the outstanding issues. Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42, 43, and supplementary standards. The home has had a positive start with service users having a generally positive experience. A lot of systems and procedures have been put in place though there are still more to organise. EVIDENCE: The changes in manager at the home have unfortunately been at a difficult time with the home being newly opened and this has caused some disruption to the stability of the home. There is a new manager, John Egbury, who has relevant experience and has been the registered manager of another home. He will need to apply for registration again with CSCI as soon as possible. He was familiar with the responsibilities of a registered manager and despite his short time at the home had already implemented some changes. His management style appeared to be open and positive, and yet he had already imposed some boundaries giving both service users and care staff a clear sense of direction. A number of positive comments about his management style were made regarding his commitment to improving things at the home, and his friendly Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 23 manner. One service user however, was not impressed due to new behaviour management techniques imposed. Feedback in the form of questionnaires completed by service users and some staff, were seen and action had been taken to address the issues raised. These had been done recently, but were not dated. They would benefit from some analysis and putting into a results sheet that could be made available to all service users, whilst keeping the comments anonymous. An annual development plan for the home was not available at this inspection, and it is recommended that everyone at the home is involved in planning for the next year. Accident records were examined and were a mixture of service users and staff. These need to be separated, the information should be expanded and some analysis done to identify problems. There was no evidence of a senior or manager having seen the records or that any risk assessments or action had been taken. The new manager stated that a new accident reporting book had already been ordered. Some training in health and safety had been done and testing of equipment such as fire systems have been implemented. The manager was aware of a number of things that required implementing such as a water risk assessment, and that despite several fire drills held some staff had not attended one. It is recommended that there is a full review of safe working practices in order to ensure that people are protected. Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 2 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 2 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Strafford House Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 2 3 2 3 3 2 3 DS0000065108.V273643.R01.S.doc Version 5.0 Page 25 N/A 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 YA6 YA6 Regulation 15 12 Requirement Review and reorganise the care plan documentation. Implement a system of recording that service users have agreed and reviewed their documentation. Implement a system of auditing of care plans by the team leaders and manager. Provide and review activity plans for all service users. Improve the recording of complaints to include action taken and outcome. Obtain local guidelines for adult and child protection and ensure that all care workers are familiar with them. A full audit of service users monies should be carried out and a review of the systems in place. The outcome of this should be forwarded to CSCI. Provide adequate heating to the bathrooms. Immediate Requirement notice issued. Provide shower curtains to those service users that would like them. DS0000065108.V273643.R01.S.doc Timescale for action 01/06/06 01/06/06 3. 4. 5. 6. YA39 YA12 YA22 YA23 24 15, 16 22 13 (6) 01/06/06 01/06/06 01/06/06 01/06/06 7. YA23 13, 16 01/07/06 8. YA24 13, 16, 23(2p) 16(2c) 31/03/06 9. YA26 01/06/06 Strafford House Version 5.0 Page 26 10. YA26 23(2b) 11. YA24 23(2b) 12. 13. 14. 15. YA24 YA28 YA24 YA24 23(2p) 23(2h) 23(2b) 23(2b) 16. YA24 23(2b) 17. YA33 18 (1) 18. 19. YA36 YA35 18 (1, 2) 18 (1) 20. 21. 22. YA37 YA42 YA42 8, 9 13, 17 Schedule 3j 13 Attend to the broken door handle of a bedroom. Immediate Requirement notice issued. Attend to the damp in the second entrance corridor and the light fitting. Immediate Requirement notice issued. Install lighting to improve safety from the car park to the home. Devise an appropriate smoking policy for the home to include the practical arrangements. Repair hole in ceiling of team leaders office. Cease use of laundry until the damp/condensation is addressed and electrical switches/ sockets are safe. Immediate Requirement notice issued. Cease use of vacant room for staff and address the problems with the staff facilities. Immediate Requirement notice issued. Ensure that adequate staff are recruited and on duty at the home as required by placement agreements. Establish regular supervision for staff as part of their development Review the training needs of individuals and compile a training plan for the home including how the targets for NVQ s will be met. The manager should apply for registration with CSCI as soon as possible. Accident records should be separated with clear information, monitored and analysed. Complete a full review of safe working practices and provide an action plan for the home to ensure these are routinely carried out. DS0000065108.V273643.R01.S.doc 10/03/06 31/03/06 01/07/06 01/06/06 01/07/06 31/03/06 31/03/06 01/06/06 01/06/06 01/07/06 01/07/06 01/06/07 01/06/07 Strafford House Version 5.0 Page 27 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. 6. 7. 8. Refer to Standard YA13 YA16 YA20 YA20 YA24 YA34 YA39 YA39 Good Practice Recommendations Consider the provision of more drivers of the minibus to facilitate more outings. Provide more support for household tasks. Obtain a medication refrigerator. Ask the supplying pharmacist to visit and assess medication facilities and administration. Attend to the settlement cracks and resulting decoration. Reorganise staff files in order to separate the different places of work. The questionnaires completed by service users and staff could be dated and analysed to assist with quality assurance. Consult with service users, staff and visitors and produce a development plan for the home. Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ National Enquiry Line: 0845 015 0120 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 Strafford House DS0000065108.V273643.R01.S.doc Version 5.0 Page 29 - 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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