CARE HOME ADULTS 18-65
Sunflower Villa 22 Wingfield Road Trowbridge Wiltshire BA14 9ED Lead Inspector
Tim Goadby Key Unannounced Inspection 12th September 2006 10:00 Sunflower Villa DS0000028443.V309426.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 Sunflower Villa DS0000028443.V309426.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. Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Sunflower Villa Address 22 Wingfield Road Trowbridge Wiltshire BA14 9ED 01225 762043 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) sunflower.villa@craegmoor.co.uk www.craegmoor.co.uk Parkcare Homes Limited Mrs Nicola Jane Gardner Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 6th January 2006 Brief Description of the Service: Sunflower Villa provides care and accommodation for up to six adults with a learning disability. The home is operated by a subsidiary of Craegmoor Healthcare, a private sector organisation with four registered care homes within Wiltshire. The service has been open for just over ten years, initially under different ownership. The home provides long-term placements, and the current service user group is well established. The property is in a residential area of Trowbridge. A range of amenities are available in the town itself. Larger centres, such as Bath and Bristol, are within reasonable travelling distance. The home is a three storey semi-detached property. All service users have single bedrooms, one of which is on the ground floor. Communal facilities are also downstairs, along with the staff office and sleep-in room. Toilets are available on all three floors. The ground floor has a shower, and the two upper floors both have bathrooms. The home also has a pleasant enclosed garden at the rear. Fees charged for care and accommodation range between £915 and £1139 per week, depending upon the assessed needs of individual service users. Information about the home is available in written form, and can also be supplied in picture or audio versions if required. CSCI inspection reports can be seen in the home, and the manager has also developed a folder of relevant information about the Commission. Interested people are also directed to the websites for both Craegmoor and the CSCI. Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key inspection was completed in September 2006. Since the previous main inspection, in January 2006, the Commission has had some further contact with Sunflower Villa, as part of a multi-agency adult protection process. This related to allegations of misconduct against one employee, who was eventually dismissed by the home. Before the visit to the service, inspection information was provided by the manager. Surveys were also completed by four service users, with support, and by six members of staff. The visit to the home lasted just over six hours. It included sampling of records, including case tracking of two service users; discussion with service users, staff and management; sampling a lunchtime meal; and a partial tour of the premises. What the service does well:
Service users have their needs and aspirations met by the home. There is an established service user group. Their strengths and needs are well understood, and suitable systems are in place to support these. All six service users were present during the course of this inspection. All appear confident and settled in their surroundings. Key documentation on individual service users, such as care plans and risk assessments, are well presented. They provide clear explanations of the support given, and the reasons for this. Reviews and evaluations are carried out at regular intervals, and in response to any changing circumstances. Service users are able to exercise choice and autonomy in their daily lives. Independence is promoted wherever possible, both at home, and when accessing community facilities. Positive risk taking is encouraged, with the use of relevant professionals in assessing suitable ways to manage situations so that opportunities can be provided. Service users are involved and consulted about their own care, the conduct of the home, and the operation of Craegmoor generally. Management of complex needs and behaviours is carried out sensitively and effectively. Relevant issues are reported openly, ensuring the involvement of other agencies where appropriate. This enables a range of professionals to work with service users to identify approaches to help meet their needs. Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 6 Service users benefit from support in maintaining key relationships. Each person is enabled to have regular contact with the people who are important to them, such as their families. Service user surveys, completed using an accessible format, reflect their satisfaction with the service provided. Although there are few direct comments, the answers ticked, from the options given, indicate that they are content with how the home meets their needs in a number of areas. Staff feedback generally reflects positive impressions of the home and the service it provides to its users. Comments include: “There’s a really happy atmosphere and everyone works really well as a team”; “The residents are treated as individuals and are properly looked after”. What has improved since the last inspection?
There have been a number of improvements to the home, enhancing the quality of the environment for service users. After a lengthy period waiting for the work to be approved, the home has had its kitchen completely refitted. This has also helped to address some health and safety risks which arose from the previous layout. Work has also taken place to upgrade a first floor bathroom. This has included resealing the floor, to minimise the risk of flooding affecting the room below, and the installation of a new shower. The flooring in one bedroom has been replaced. Significant events affecting the safety and well-being of service users are being notified to the Commission, as required under care homes regulations. This helps to ensure that the home operates openly and transparently, and that service users have access to all possible avenues of protection and advice. Progress in the achievement of National Vocational Qualifications by care staff has enabled the service to reach the minimum 50 target specified in minimum standards. This benefits service users by increasing the number of hours of support which are delivered to them by staff qualified to a recognised level. There is clearer evidence that each employee is receiving regular supervision sessions with a manager. This provides an effective means of monitoring and developing the performance of each staff member, to the overall benefit of the service and its users. Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 7 Since the previous inspection the service has provided the Commission with a copy of its development plan. This shows that there is a commitment to improve the service, including taking steps in line with its users’ needs and preferences. Arrangements for fire safety are being implemented more effectively, ensuring greater protection for service users and others. Records now show all required checks, instruction and practices being carried out at the required frequencies. All fire preventing doors have also been fitted with suitable holdback devices, so that they can be left open safely in normal use, and will still close if the alarms sound. What they could do better:
Staff recruitment records fail to provide evidence that the process carries out all the required checks thoroughly. This places service users at risk that staff may begin working with vulnerable people before their suitability to do so has been fully checked. This issue arose as part of the adult protection process that took place regarding Sunflower Villa since its previous inspection. In that case, a staff member was accused of misconduct, and was eventually dismissed. During the investigation, it was suspected that the recruitment checks on the employee concerned had not included establishing details of their previous employment in any post working with vulnerable people, as required. The Commission wrote to Craegmoor about this matter. In their reply, they were confident that all necessary steps had been taken. This could not be verified at this inspection, as records were no longer being kept for this former employee. At this inspection, the position was once more found to be unsatisfactory. There was only one recent appointment to check, which was of a previous employee returning to the home. There were two significant gaps in this person’s records. Firstly, there was no reference from the care employment the person had undertaken between leaving and returning. There was also no suitable written evidence about their reason for leaving this post after a relatively short time. Secondly, evidence of criminal record checks was insufficient. There was no record of an initial check of the national list of those who must not be employed to work with vulnerable people. Evidence relating to a criminal record check consisted only of an undated handwritten note, which was not suitable to demonstrate that this had been completed appropriately. The ceiling in the ground floor lounge is in need of repair and redecoration, as there has been another recent incident of damage to this by flooding from the bathroom above. Although the floor in that room has now been sealed effectively, the problem occurred when some water got out under the door and
Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 8 on to the landing. This remaining gap is to be blocked off, and the ceiling then restored to the necessary condition. Developments in record keeping could enhance the care provided to service users. These include ensuring that all key documents, such as risk assessments, are signed; and that the dates when fire drills are held are included in the record of these sessions. An emergency relocation plan, showing the contingency arrangements if the home had to be evacuated, should also be documented. 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. Sunflower Villa DS0000028443.V309426.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 Sunflower Villa DS0000028443.V309426.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area was not assessed. Standards relating to admissions to the home were not applicable at this inspection. EVIDENCE: There have been no admissions of service users to Sunflower Villa since 2000, so the key standard for this section could not be assessed at this inspection. Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users’ needs and goals are reflected in their individual care plans. Service users are supported to exercise choice and control in all aspects of their daily lives. Systems for risk management support the undertaking of social opportunities. EVIDENCE: Two sets of service user records were sampled at this key inspection. As on previous occasions, these were seen to be well maintained. They contained a range of clear information about each aspect of an individual, including their life history, strengths and needs, support required, risk assessments and management strategies. There is evidence of the input of the service user themselves. For instance, records of review meetings show what contributions they make.
Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 12 Service users are positively encouraged to get involved in discussing their own support needs, and identifying possible ways to address these. This approach is known to be the best way of engaging with some individuals. For instance, service users may take part in negotiating a suitable contract about minimum standards to be maintained in areas such as personal care and the cleanliness of their own room. This helps to promote an appropriate balance between individual choice and the home’s duty of care. A staff keyworker system is used, allocating specific responsibility for particular service users amongst the team. In some cases service users may have two keyworkers, to help prevent relationships becoming too intense, or to reflect the amount of work involved. A record is kept of any suggestions made by service users, and of the actions taken in response. There are examples of residents of the home contributing directly to these records. Changes have been made as a result of the comments received. Residents’ meetings also take place regularly. Records showed that there had been five of these in the three months before this inspection visit. In addition, some service users from Sunflower Villa have been to a larger Craegmoor event, at the organisation’s head office, where they represented the home and the views of its resident group. Two service users are also members of a local self-advocacy group, which promotes people with learning disability speaking up for themselves on a range of issues. During inspection visits, it has been observed that service users are free to choose how they spend their time at home. This includes whether to be in their own room or a communal area; and where they would prefer to have a meal. Risk assessments consider positive reasons to take risks, as well as potential negative outcomes. Where possible, they place emphasis on the support that will enable an opportunity to be undertaken. Other professionals, such as occupational therapists, have been involved in these processes. Assessments and management strategies are reviewed in response to any significant changes. The level of support may be reduced or increased, depending on particular situations. If restrictions are imposed, the reasons for this are clearly explained. Sunflower Villa DS0000028443.V309426.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users have frequent opportunities to undertake a range of activities, both at home, and within their local community. Service users are supported to maintain personal and family relationships. Daily lives for service users have an appropriate balance between necessary routine, and individual choice. Arrangements for the provision of meals promote independence, choice and social inclusion. EVIDENCE: Weekly programmes vary, depending on people’s needs and preferences. Not all service users wish to access facilities outside the home. For those that do, the places attended include the local college, day centre and a garden centre.
Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 14 College sessions were just restarting after the summer break, and service users spoke about the various courses they were now going to attend. When people are not attending other resources, activities are supported by staff of the home. The aim is to encourage everyone to get out at least once a day. A range of amenities are accessed in the local community, such as shops and pubs. Many service users are able to do this independently. Risk management strategies are in place. The home has been successful in enabling some individuals to become more independent, using a structured approach to develop their skills. The home has its own vehicle, which is used when needed. Trips further afield include regular outings to the cinema, and ten pin bowling. All service users have regular family contact. This is maintained by phone calls and visits. Some individuals spend weekends with their relatives. On the day of this unannounced inspection one service user was visited by their father in the morning. Another’s mother attended for a review meeting, and then she and her daughter went out for lunch together. Service users are also supported to go away on holiday. Photos from a number of these trips are displayed in the home. One service user spoke about a recent holiday which they had particularly enjoyed. Others prefer day trips, and outings during the summer this year included Weymouth, Longleat, Stonehenge and a barge trip. At home, people choose whether to spend time in their own rooms, or in communal areas. Some environmental restrictions are in place. The staff office is locked when not in use. The first floor bathroom is also locked, for reasons which are clearly documented. The pantry is used to ration access to food, and keep potentially hazardous items out of reach. The kitchen remains open at all times. Service users participate in normal daily household tasks, in line with their ability levels. They spoke about various examples, such as shopping, laundry and cleaning. The main meal is served in the evening. Service users have a light lunch if they are at home during the day. During this inspection visit the midday meal was jacket potatoes, with a choice of fillings. Menus are drawn up, based on the choices of service users. Alternatives are provided if necessary. People can also make drinks and snacks independently, if able to do so. Specific issues relating to food and diet for individual service users are set out within their care records. Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 15 Meals can be taken in the dining room, where staff and service users eat together. But people can also choose to eat in their own rooms, if they prefer. Sunflower Villa DS0000028443.V309426.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are supported to address their personal and health care needs effectively. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Service users are supported to address their various health care needs. There is evidence that all relevant professionals are involved. People have access to medical advice, from both GPs and consultants. They are also up to date in other areas, such as dental care. Relevant indicators of health, such as weight, epileptic activity, or behaviour, are monitored within individual records. A community nurse specialising in learning disability has drawn up a detailed epilepsy profile for service users who have this condition. Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 17 None of the home’s service users currently retain their own medication, so staff are responsible for this task. All staff receive training in this topic as part of their overall induction. Systems for the management of medication are appropriate. A procedure governs practice in the home. There is suitable and secure storage. This has recently been relocated. Medication records are properly maintained, and each administration chart is accompanied by a photo of the service user, to aid identification of who is to have which drug. Administration is carried out by two staff, so that each can double check that the right medicine is being given, and is then recorded correctly. One staff survey commented that medication records are not always completed correctly. However, at this unannounced visit the sample seen were all maintained appropriately. For instance, one service user was in the process of having one drug reduced by a number of steps over a few weeks. Records for this had been maintained exactly in line with the prescribing instructions. Some service users have medication which is prescribed to be given ‘as required’. There are individual protocols which set out the circumstances in which these prescriptions may be given. These documents show the input of any other professionals who have contributed to drawing them up. If ‘as required’ medication is administered there is clear recording, both on the medication chart, and in the person’s daily notes. Medicines available without prescription may also be given to service users. The home has obtained signed agreements from service users’ GPs about which of these ‘homely remedies’ they may take. Sunflower Villa DS0000028443.V309426.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are safeguarded by the home’s policies and procedures for complaints and protection. EVIDENCE: Craegmoor has appropriate procedures in place for complaints and protection. These are readily available in the home. Complaints information includes contact details for relevant senior people in the organisation, and for other agencies, such as the CSCI. There is also a pictorial version, intended to be more accessible for service users. Complaints records are kept in the home. These show that there is a detailed response when formal complaints are received. Sunflower Villa supports some service users who may present with episodes of disturbed behaviour. These issues are clearly set out in individual records, with appropriate management strategies in place. The guidance is developed with input from relevant professionals. Staff receive training on how to deal with such situations, and display a good knowledge of the best ways to support the people that they work with. All staff receive training in issues of abuse and protection as part of their induction. Information within the home about adult protection includes details of the local multi-agency procedures. Referrals have been made to these when necessary. For instance, when significant incidents have occurred between
Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 19 service users. This has helped to ensure appropriate review of how such difficult situations are managed. A referral also took place since the previous inspection due to an allegation of serious misconduct by one employee. This eventually led to the dismissal of the employee concerned, and Craegmoor referring the individual for inclusion on the national list of those considered unsuitable to work with vulnerable people. Within the home, systems were also reviewed to minimise the risk of any similar issues recurring in future. Arrangements for the storage and recording of service users’ money were viewed during the inspection. These were seen to be appropriate. Sunflower Villa DS0000028443.V309426.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users live in a safe, comfortable and clean environment, suitable to their needs. Some improvements are needed to specific areas of décor to ensure the overall quality of the property. EVIDENCE: Sunflower Villa is a semi-detached property in a residential area. It blends in with surrounding houses. There is easy access to local amenities, and to public transport. All service users have single rooms. One of these is on the ground floor. Toilets and washing facilities are also available on all three floors. There is a shower on the ground floor. The first floor bathroom is kept locked when not in use, due to the known behaviours of a service user. Reasons for this are clearly documented. Communal areas are on the ground floor. The lounge is at the front of the house, and provides a natural focal point. Further back, the dining room leads through to the kitchen and utility room. The staff office and sleep-in room are
Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 21 at the rear. The home also benefits from a large area of enclosed garden, which is used during good weather. One service user is keen on gardening, and has successfully grown their own tomatoes. There have been a number of improvements to the home over recent months. The flooring in the ground floor bedroom has been replaced, and is now of a type more suitable to the needs of the occupant of this room. It is also hoped to install an en-suite shower in this bedroom, which would remove the need for the service user to go through communal areas to the existing ground floor shower. The first floor bathroom has had a new shower installed, and also the floor resealed. This should help to prevent flooding affecting the ceiling in the lounge below. Unfortunately there had been a recurrence of this problem shortly before this inspection, as water got out under the door and then leaked down via the landing. The door is now also to be sealed, and the damaged ceiling in the lounge will have to be repaired and redecorated again. It is also planned to replace the bath taps with a design which cannot be left running as easily. The kitchen has been completely refitted, which has improved the look of this area, and also helped to address health and safety issues which arose from the previous layout. The cooker is now situated centrally against a wall, rather than right by a doorway. The home was clean and hygienic in all areas seen during this unannounced inspection. There are suitable systems in place for maintaining cleanliness. These include procedures relating to infection control. For instance, laundry is taken through to the home’s utility room via a route which avoids the kitchen and dining room, if necessary. Sunflower Villa DS0000028443.V309426.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 & 36 Quality in this outcome area was adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are supported by suitable numbers of appropriately trained staff. Service users are placed at risk by failure to provide evidence that all required recruitment checks are completed before new staff begin working with them. EVIDENCE: Staff are provided at all times. There are a minimum of two staff on duty for all daytime shifts. This is often increased to three, due to the presence of the manager or deputy. At night, one person sleeps in. If there are shortages in the rota, these are usually covered by the home’s staff working additional hours. Occasionally relief or agency workers may also be used. Sunflower Villa also has nine hours per week domestic cover, spread over three shifts; and ten hours of maintenance support, covering two days. There is an on-call system, so that staff on duty can have access to advice and support from a senior colleague if they need this. The service was in the process of recruiting to one vacant part-time post, and another employee was shortly due to go on maternity leave.
Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 23 Concerns about the service’s recruitment practices arose since the previous inspection, due to an adult protection investigation which focused on alleged misconduct by an employee of the home. It was suspected that not all the necessary information about this individual’s employment history had been obtained by Craegmoor when they were appointed. This concern was put to the organisation, who responded that the necessary steps had been taken. The employee has since been dismissed, so their records could no longer be checked at the home. At this inspection, there had only been one recent appointment. This was the re-employment of a person who had left for a few months to take up another job within the care sector. A full recruitment process was stated to have been carried out, as required. But the records seen during the inspection were deficient. There were two written references, but no reference from the person’s care employment between leaving and returning, or suitable written evidence of the reasons for ceasing this employment. The curriculum vitae supplied by the employee also gave an incomplete employment history, as it had not been updated since initially leaving Sunflower Villa. Evidence of criminal record checks, including of the national list of those who must not be employed to work with vulnerable people, was insufficient. There was no information relating to a check of the list. The only evidence of a criminal record check was a handwritten note quoting a disclosure number, and stating that no convictions or cautions had been found. No date was given for this disclosure form. In the absence of a disclosure form itself, evidence must be available as a letter of confirmation from the body which obtained the disclosure, showing the date, the number and the information contained. Craegmoor has an area training co-ordinator. Training records are kept for all employees. These show which courses everyone has attended, and when they are next due for refresher sessions. The service is above the 50 target for care staff with National Vocational Qualifications at Level 2 or higher. Five staff have achieved this award. The manager and deputy both act as supervisors for the other staff at Sunflower Villa. Sessions are held using a format developed by Craegmoor. These usually take place every two months. Records are kept in a booklet, and signed by both the employee and the supervisor. All sessions contribute towards an overall annual appraisal system. Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 24 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, 39 & 42 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. The registered manager is suitably competent and experienced, so that service users benefit from a well run home. Quality assurance measures underpin service developments, and include actions based on the views of service users. Service users’ health and safety are protected by the systems in place. EVIDENCE: Ms Nichola Gardner returned to Sunflower Villa for a second spell as its manager during 2005. She has a range of relevant experience, and is now completing the management qualifications which all registered managers are required to attain. Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 25 The home’s deputy manager, who works 21 hours per week, is also undertaking an NVQ Level 4 award. Craegmoor’s services are extensively audited by the organisation. It has a ‘Clinical Governance’ team, aiming to ensure that all establishments achieve a minimum standard of performance, and then promote them to move beyond this to reach a level of excellence. Information about the organisation’s various systems and procedures is available to all of its services via its internal computer links. The manager has to submit various weekly and monthly reports. There are also visits to the home by senior managers. In addition to this, steps are also taken to involve as many staff as possible in the various audits of different areas of service delivery. This helps to promote their understanding of quality assurance. Service users’ meetings are held at least once a month. Records are kept of these sessions, which are an opportunity for the home’s residents to make their views and wishes known. Relatives are also surveyed for their feedback periodically. From the various sources of evidence used, a service development plan is drawn up. This includes proposals to address any deficits identified, and also to build on areas of existing strength. There are a range of records in place relating to various checks carried out to maintain health and safety. There is a local committee within Craegmoor which meets regularly to discuss relevant issues on this topic. All checks, instructions and practices relating to fire safety are recorded as being carried out and up to date. Records of fire drills include the response of service users as well as staff. However, although it is shown in which quarter they were conducted, the actual date is not noted. A recommendation from a fire risk assessment by an external contractor in September 2005 was for the home to have an emergency relocation plan. The contingency plan involves the probable use of another nearby property owned by Craegmoor, but this has not yet been documented. Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 26 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 N/A 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 2 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 3 36 3 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 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 27 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 YA24 YA34 Regulation 23-2b,d 7;9;19 Sch2-3,4 Requirement Repair and redecoration must take place to the lounge ceiling. Staff recruitment records must include all required information relating to written references and a full employment history. Staff recruitment records must include evidence that the required POVA and CRB checks have been completed at the appropriate times. Timescale for action 31/12/06 12/09/06 3 YA34 7;9;19 Sch2-7 12/09/06 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 YA9 YA42 Good Practice Recommendations Care should be taken to ensure that all risk assessments are signed by those completing them. The dates on which fire drills are carried out should be included in the record of these practices.
DS0000028443.V309426.R01.S.doc Version 5.2 Page 28 Sunflower Villa 3 YA42 The service should have a documented emergency relocation plan. Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Sunflower Villa DS0000028443.V309426.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
