Inspection on 06/01/06 for Wingfield Road Care Home

This inspection was carried out on 6th January 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wingfield Road Care Home 12/09/06

Wingfield Road Care Home 12/08/05

Wingfield Road Care Home 18/11/04

Wingfield Road Care Home 21/04/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Sunflower Villa 22 Wingfield Road Trowbridge Wiltshire BA14 9ED Lead Inspector Tim Goadby 6th & 11th January 2006 Unannounced Inspection 15:45 – 19:25; 09:35 – Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 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.V276852.R01.S.doc Version 5.1 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.V276852.R01.S.doc Version 5.1 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 (No. 2) Limited Mrs Nicola Jane Gardner Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th August 2005 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 for this client group within Wiltshire. The service has been open for around ten years, initially under different ownership. The home aims to provide 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. Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two visits in January 2006. The first of these was unannounced. The second took place the following week, by appointment, to meet with the manager. This enabled the inspection to be concluded, and initial feedback to be given. A total of 5.5 hours was spent in the home over the two visits. The following inspection methods have been used in the production of this report: indirect observation; sampling of records; sampling a meal; discussions with service users, staff and management; survey of service users. What the service does well: What has improved since the last inspection? Records available for inspection in the home show all the actions taken in response to any formal complaints received. This helps to demonstrate that all appropriate actions are taken, upholding the welfare of service users, and respecting the rights of complainants. Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 Page 6 What they could do better: A number of requirements from the previous inspection remain unmet, and some additional issues have been identified. This demonstrates poor compliance with the expected standards for a care home, and is to the detriment of the service users. Not all significant events affecting the safety and well-being of service users are notified to the Commission, as is required under care homes regulations. Examples noted at this inspection include episodes of disturbed or aggressive behaviour, also involving other service users or staff; and significant changes in needs for some individuals, leading to consideration of whether placement at the home may need to be reviewed. Notification is needed to ensure that the home operates openly and transparently, and that service users have access to all possible avenues of protection and advice. The flooring in one bedroom is still in need of replacement, to ensure that there are no offensive odours in the room. This step will improve the quality of service users’ environment, and uphold the dignity of the individual most directly affected. The home’s kitchen has been awaiting a complete refit for more than a year, and this has still not been actioned. The failure to do so places service users and others at risk, because the current layout has the cooker situated in a particularly hazardous position. Service users and others are placed at risk by a number of deficits relating to fire safety. Not all required checks are being carried out and recorded at the required frequencies. Similarly, staff are not receiving instruction in the topic regularly enough. Some fire preventing doors need to be provided with suitable holdback devices, so that they can safely be held open in everyday use. Another area still awaiting repair is a first floor bathroom, which needs resealing work. Following on from this, the ceiling in the ground floor lounge directly below needs repair and redecoration, where it has been affected by water damage. The failure to carry out such works in a timely fashion detracts from the comfort and cleanliness of service users’ home environment. More progress is needed in care staff obtaining National Vocational Qualifications (NVQs) in care, to reach the 50 target required in care homes standards. This will benefit service users by increasing the number of hours of support which are delivered to them by staff qualified to a recognised minimum level. The home needs to demonstrate effective practice in all aspects of recruitment and selection of staff, to ensure the protection of service users. If new workers take up their posts before the completion of a full criminal record check, there must be evidence that their deployment is in line with the criteria Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 Page 7 set out in care homes regulations, which require additional monitoring arrangements in such circumstances. Each employee has individual supervision sessions with a manager, but these need to happen at least six times per year to meet the standard. This will provide an effective means of monitoring and developing the performance of each staff member, to the overall benefit of the service and its users. The home needs to produce evidence of an annual development plan, to ensure that the service is conducted and developed in line with service users’ needs and preferences. 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.V276852.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standards relating to admissions to the home were not applicable at this inspection. Service users have their needs and aspirations met by the home. EVIDENCE: The home has not had any new admissions since 2000. The current service user group is well established. Information is available to describe their needs, and the strategies to support these. Staff support is in place for all service users throughout the day. A range of professionals and resources are also accessed, to assist the home in meeting its service users’ needs. The majority of Sunflower Villa’s service users are independent in a number of areas, both at home and outside. Some need more input. These differences are clearly set out in the information about each individual, and support is tailored accordingly. When any service user has significant changes in their needs, appropriate steps are taken to respond to this. Other professionals are involved in carrying out re-assessments, and planning for any appropriate steps to meet the new situation. Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 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): 7 Service users are supported to exercise choice and control in all aspects of their daily lives. EVIDENCE: 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. For instance, there is now a regular Friday evening activity, as requested by one individual. Residents’ meetings also take place regularly. Minutes of the last four of these sessions show that a range of issues are discussed. Topics include planning social events, choosing new furniture for the home, and deciding on activities to undertake. Two service users from Sunflower Villa had also been chosen to go to a larger Craegmoor event, where they could represent the home and the views of its resident group. Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 Page 11 During the inspection, it was clear that service users are free to choose how they spend their time at home. This includes simple matters such as whether to be in their own room or a communal area; and where they would prefer to have a meal. Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 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): 12, 13, 14, 15 & 16 Service users are provided with a range of activities and opportunities, offering them full engagement with their local community. Service users are able to maintain and develop appropriate relationships with family and friends. Service users’ rights and responsibilities are upheld, balanced with appropriate steps to safeguard their welfare. EVIDENCE: Issues of choice and autonomy are addressed in service user records. There is a focus on promoting independence. If restrictions are imposed as part of overall care, there are clearly documented reasons. Weekly programmes vary, depending on people’s needs and preferences. Facilities attended include the local college, and a garden centre. Service users spoke about the sessions they participate in, which include woodwork, literacy, swimming, and independent living skills. Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 Page 13 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. Service users are also supported to go away on holiday. Photos from a number of these trips are displayed in the home, and people spoke about some of the places they have been. 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. Observed interactions amongst service users and staff were positive. Staff are conscientious in drawing people into conversations, and ensuring that they are given the chance to speak for themselves. Service users participate in normal daily household tasks, in line with their ability levels. On the first of the two visits forming this inspection people were observed helping out with various jobs before, during and after the serving of the evening meal. One person then did the hoovering independently. Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 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): 19 & 20 Service users are supported to address their health care needs effectively. Service users are protected by the home’s policies and procedures for dealing with medicines. Further guidance will need to be developed to support the use of a drug which may be prescribed for one person. 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. None of the home’s service users currently retain their own medication, so staff are responsible for this task. Systems for the management of medication are appropriate. A procedure governs practice in the home. There is suitable and secure storage. 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 Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 Page 15 two staff, so that each can double check that the right medicine is being given, and is then recorded correctly. 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. One new medicine has recently been prescribed for a service user. The drug in question has to be given in a certain way, and staff will need training in the relevant technique. There are also additional recommendations relating to storage and recording of the drug, which the home has not yet implemented. As no suitable staff training has yet been identified, the manager decided to return the drug to the pharmacy. The inspector recommended that the home should get further guidance on this issue before any decision is taken on whether to go ahead with the prescription. Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 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 Service users are safeguarded by the home’s policies and procedures for complaints and protection. The home has failed to notify the Commission of all events adversely affecting the safety and well-being of service users, which would help to ensure that service users have access to all possible avenues of protection and advice. 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. The home 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. Records show that not all significant events affecting the safety and well-being of service users have been notified to the Commission. The sampled file of one individual contains four examples of such incidents since the previous Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 Page 17 inspection, which also involved other service users or staff. Reported changes in the needs of some people, giving rise to concern about their placement in the home, have also not been notified as they develop. Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Service users’ environment is generally suitable overall, but needs attention to some specific areas of décor and cleanliness. EVIDENCE: Sunflower Villa is a semi-detached property in a residential area. It presents as no different to the surrounding houses. There is easy access to local amenities, and to public transport. The home is generally well maintained. But when there are jobs requiring attention, progress is slow. Relevant issues and requirements from previous inspections have not been addressed. Quotes have been obtained for necessary work, but then the expenditure has not been authorised. In particular, the kitchen and the first floor bathroom are due for complete refurbishment. The ceiling in the ground floor lounge also needs attention, where it has been damaged by water from the bathroom above. Most areas of the home are clean and hygienic. But there is a problem with a strong offensive odour in one room on the ground floor. This creates an unpleasant environment for the individual concerned, and also presents a poor Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 Page 19 overall impression of the home for any visitors. The problem is due to be addressed by replacing carpet with a more easily cleanable floor surface. Toilets and washing facilities are available on all three floors of the home. These include 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 at the rear. The home also benefits from a large area of enclosed garden, which is used during good weather. Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 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 Service users are supported by suitable numbers of staff. The home is unable to evidence that appropriate recruitment processes are in place, to ensure the protection of service users. Staff receive relevant training to assist them in meeting service users’ needs effectively. More progress is needed in care staff obtaining nationally recognised qualifications. Staff are supported and supervised, but the frequency stipulated within standards needs to be reinstated. EVIDENCE: The staff team at the time of this inspection consisted of a manager, a parttime deputy, three full-time and three part-time support workers, one of whom usually covered just one shift per week. 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 DS0000028443.V276852.R01.S.doc Version 5.1 Page 21 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 home had experienced some staffing pressures over the weeks before this inspection. The situation was now set to ease. One person was about to return from maternity leave. A new senior support worker was also about to begin working full-time. Craegmoor’s recruitment process follows all the necessary stages. Advertising, interviewing and selection are carried out locally. The organisation’s central human resources department then carries out the full range of employment checks, before a provisional job offer can be confirmed. These include obtaining proofs of identity, written references, and criminal record checks. The records for two recently appointed staff were sampled. These showed that the majority of required information is in place. One person had a risk assessment on file, reflecting that there had been some additional issues for consideration at the selection stage. One employee had begun working at the home after receiving satisfactory clearance from a POVA First check, which establishes that the person’s name does not appear on the national list of those deemed unsuitable to work with vulnerable adults. The person had not yet received their full criminal record disclosure. Care homes regulations permit an employee to work in such circumstances, but there are strict criteria laid down for this, to ensure additional monitoring of the person. The home was not recognising these in its deployment of the individual concerned. It was agreed at the inspection that a risk assessment would be completed to support the appropriate use of this worker, and the protection of service users. This document was produced to the Commission immediately after the inspection. 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. A new approach to induction and foundation training has just been implemented across the organisation. This links to national occupational standards for the social care workforce, and to those particularly developed for staff working with people with a learning disability. Successful completion of this package also provides workers with a pathway into studying for National Vocational Qualifications (NVQs). New staff are assigned a ‘supportive colleague’ who will shadow and assist them during the early stages of their employment. At Sunflower Villa, the deputy manager takes on this role. Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 Page 22 Because the home has a number of new employees at present, it has fallen below the 50 target for care staff with NVQs in care at Level 2 or above. At present, two support workers have this award, and they cover 49 hours per week between them. The full-time senior support worker who was about to take up post also has the NVQ Level 2. The two staff on duty on the first visit for this inspection are both fairly new to the home. They confirmed the range of training they have already undertaken. In addition to working through their induction process, they have attended courses in topics including food hygiene, infection control, fire safety, and adult protection. More training was due shortly after this inspection, including moving and handling, first aid, and information about epilepsy. Staff also reported that they had been directed to read lots of key information. In addition, staff meetings are used to discuss various issues relevant to the support of service users, and the running of the home. Occasionally, sessions will be arranged on specific topics, such as autism. Staff receive one-to-one supervision sessions with a senior colleague. Records are kept of these meetings. The required frequency has reduced in recent weeks, due to staff pressures. Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 Page 23 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 The registered manager is suitably competent and experienced. Quality assurance measures must produce a plan which ensures that the home is conducted and developed in line with service users’ needs and preferences. Fire safety measures need attention, to ensure that the welfare of service users is promoted and protected. The layout of the kitchen presents risks to the safety of service users and staff. EVIDENCE: Ms Nichola Gardner returned to Sunflower Villa for a second spell as its manager during 2005. She has recently completed the process of registration with the CSCI. Nichola has a range of relevant experience, and is now working towards the qualifications which all registered managers are required to attain. Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 Page 24 The home’s deputy manager, who works 21 hours per week, is also planning to undertake 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. The manager has to submit various weekly and monthly reports. There are also visits to the home by senior managers. Service users’ meetings are held 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. The next such exercise is due in February 2006. No development plan for the service was available for inspection. The manager reported that one had been drafted in November 2005, and sent off for authorisation within Craegmoor. It had not been returned to the home at the time of this inspection, and no copy could be produced. As at the previous inspection, fire safety records show deficits in the required frequency of checks. The alarm system must be checked at least once a week. Records for the period since the inspection of August 2005 show six separate occasions where this was not achieved. The longest recorded gap between checks is 28 days. Overall, between August and the beginning of December 2005, there were only nine checks within an 18 week period. Checks did take place each week for the six weeks immediately before this inspection. Emergency lights must be tested at least once a month, but this was not done in either September or October 2005. Fire drills were carried out at least once in each three month period during 2005, as required. But staff must also receive instruction in fire safety with the same frequency. The home has previously only been carrying this out once in every six months. Although the set frequency has now been amended in the relevant log book, no staff are recorded as receiving such training for the final quarter of the year. In addition, records for earlier in the year note one employee as declining the training. This is not acceptable. The home’s fire risk assessment was updated in September 2005, by an external contractor engaged by Craegmoor. At Sunflower Villa, this exercise has identified certain actions needing to be taken. One of these is to provide suitable holdback devices for fire preventing doors around the laundry room area. At the moment, the only means of holding them open is with cabin hooks, which means that they will not provide the required protection in the event of a fire. Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 Page 25 There are suitable emergency procedures, which set out the actions to take in the event of suspecting a fire. Staff are instructed to take different actions, depending upon whether the incident occurs during the day, or at night. In response to a recommendation discussed during the inspection, the procedures have been amended to make the layout of the guidance clearer. An unmet requirement from two previous inspections relates to the siting of the cooker. This is in an area by a through route between the kitchen and utility room, which is in frequent use. This has been identified as a health and safety risk. The home plans to address the problem within an overall refit of the kitchen. But this work still remains outstanding. In the interim, there is a risk assessment which sets out how to manage the current situation to minimise the likelihood of any harm occurring. Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 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 3 4 N/A 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X 3 X 2 X X 2 X Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 Page 27 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA23 Regulation 37-1e Requirement The persons registered must notify the Commission without delay of any event which adversely affects the well-being or safety of any service user. (Timescale from 12/08/05 not met) Repair and redecoration must take place in the first floor bathroom, and the ground floor lounge below. The persons registered must ensure that the home is kept free from offensive odours. (Timescale of 30/09/05 not met) COMMENT: The floor covering in the affected room is due to be replaced. The persons registered must take suitable steps to provide a minimum 50 of care staff with NVQ Level 2 or higher. COMMENT: The timescale reflects the next point by which this will be reviewed by the CSCI. There must be documented evidence to support the DS0000028443.V276852.R01.S.doc Timescale for action 11/01/06 2 YA24 23-2b,d 31/03/06 3 YA30 16-2k 31/03/06 4 YA32 18-1a,c 30/09/06 5 YA34 12-1 19- 11/01/06 Sunflower Villa Version 5.1 Page 28 4,9,10,11 appropriate deployment of any staff still awaiting full CRB clearance. COMMENT: This requirement was addressed immediately after the inspection. This part of Regulations also applies to the above requirement. All staff must have recorded supervision meetings at least six times a year. COMMENT: The timescale reflects the next point by which this will be reviewed by the CSCI. There must be an annual development plan for the home. 5 6 YA34 YA36 17-2 Sch4-6f 12-5a 18-2a 11/01/06 30/09/06 7 YA39 24 30/09/06 8 YA42 13-4a 9 YA42 23-4c,d,e 10 YA42 23-4a, c(i) COMMENT: The timescale reflects the next point by which this will be reviewed by the CSCI. The persons registered must 31/03/06 ensure that the cooker is guarded, or relocated to a safer position. (Timescale of 28/02/05 not met) There must be evidence that all 11/01/06 required checks and instruction relating to fire safety are carried out at the prescribed intervals. (Timescale from 12/08/05 not met) Fire preventing doors must not 11/01/06 be held open, unless this is by means of a suitable device which will ensure their closure in the event of the alarm system activating. Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 Page 29 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 Refer to Standard YA6 Good Practice Recommendations The home should continue steps to promote greater input of service users into their own care plans. COMMENT: This recommendation of the previous inspection was not checked on this occasion. Risk assessments should be reviewed, to reduce any unnecessary duplication. COMMENT: This recommendation of the previous inspection was not checked on this occasion. Guidance should be obtained on the arrangements for management of a specific drug which may be prescribed for a service user. 2 YA9 3 YA20 Sunflower Villa DS0000028443.V276852.R01.S.doc Version 5.1 Page 30 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.V276852.R01.S.doc Version 5.1 Page 31 - 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!