Inspection on 18/04/07 for Sunnybrook Close (6)

This inspection was carried out on 18th April 2007.

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

Other inspections for this house

Sunnybrook Close (6) 06/06/06

Sunnybrook Close (6) 12/12/05

Sunnybrook Close (6) 01/12/04

Sunnybrook Close (6) 18/05/04

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Pinta

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Sunnybrook Close (6) 6 Sunnybrook Close Aston Clinton Aylesbury Buckinghamshire HP22 5ER Lead Inspector Nancy Gates Unannounced Inspection 18th April 2007 02:45 Sunnybrook Close (6) DS0000028528.V331843.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 Sunnybrook Close (6) DS0000028528.V331843.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. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sunnybrook Close (6) Address 6 Sunnybrook Close Aston Clinton Aylesbury Buckinghamshire HP22 5ER 01296 630038 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) Hightown Praetorian & Churches Housing Association vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2006 Brief Description of the Service: 6 Sunnybrook Close is a detached property, situated at the end of a cul de sac in the village of Aston Clinton on the outskirts of Aylesbury. ‘The home’ provides care and accommodation for adults with learning and physical disabilities and is registered for up to three people who use the service. The home is run and managed by Hightown Praetorian and Churches Housing. Sunnybrook Close provides single room accommodation for all people who use the service and has been sympathetically refurbished to provide for their needs. There is a private garden to the rear of the property and to the front of the home there is ample car parking space for approximately six vehicles. The home is situated close to public houses, green park and a small local shop. Aylesbury and surroundings areas are accessible by transport. The current fees range from £2298.76 to £2226.70 per week. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of the service was an unannounced ‘key inspection’. The inspector arrived at the service at 2.45 p.m. on the 18th April 2007. The total number of hours spent at the home was 5 hours. The time spent at the home allowed for a thorough look at how well the service is doing. The inspection took into account detailed information provided by the service manager inclusive of information that CSCI has received about the service since the last inspection. All household members were in the home at the time of inspection. The inspector also requested the views of others who support the needs of the people who use the service via a questionnaire that the CSCI sent out. No comment cards were received from people who use the service, relatives or professionals involved with the home in respect of this service. Staff and residents were very welcoming. The inspector looked around the home including the bedrooms of the residents at their invitation. A number of records were viewed including a resident’s care plans, staffing rotas and maintenance records. The inspector looked at how well the service was meeting the standards set by the government. The report includes judgements about the standard of the service. What the service does well: The organisation continues to have an admissions process/procedure in place, which, indicates that prospective people who wish to use the service are fully assessed prior to admission to ensure that the service can met their needs. Care plans are in place, outlining needs, likes and dislikes and describe how a person likes to be supported. The people who use the service make decisions in everyday life, giving them choice. The people who use the service are also enabled to take risks, to promote independence. Needs arsing from equality and diversity are generally met. From the evidence seen, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial, or cultural needs. Family involvement continues to be supported and encouraged. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 6 Meals and menu planning are appropriately managed, ensuring that nutritional needs are met. Systems are in place to ensure that people who use the service personal care and healthcare needs are met and monitored which promotes their well-being. Improvements have been medication practices that ensure the safety of people who use the service. A complaints procedure is in place and which allows for complaints to be investigated and responded to, which indicates that concerns are acted on to benefit people who use the service. Policies and procedures are in place to ensure the protection of people who use the service. Update training on adult protection/safeguarding adults has been provided for staff. The home is generally clean, homely and systems are in place to maintain this to provide a safe environment for people who use the service. What has improved since the last inspection? What they could do better: Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 7 Care plans are in place, outlining needs, however plans must be reviewed, and updated with the people who use the service to ensure needs are being met. There is a limited range of purposeful activities on offer. Individual interests, and choices are not supported on a regular basis, preventing people from trying new experiences and taking part in activities that they enjoy. Daily routines do not always promote service user involvement and independence which potentially could prevent people who use the service from been given responsibilities in their daily lives. Systems are in place to ensure that people who use the service personal care and healthcare needs are met and monitored which promotes their well-being. However, some aspects of individuals healthcare needs are being undertaken by staff who have not been appropriately trained therefore the safety of the people who use the service cannot be assured. Improvements are required to the garden to make it more accessible and suitable for people who use the service. The home does not have the required records available to confirm if all staff have been properly recruited and have received appropriate training. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 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 Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The organisation continues to have an admissions process/procedure in place, which, indicates that prospective people who wish to use the service are fully assessed prior to admission to ensure that the service can met their needs. EVIDENCE: There have been no admissions to the home since the last inspection. The organisation continues to have a policy and procedure in place that outlines the steps to take prior to admission, upon admission and following admission. The policy and procedures indicate that the registered manger is involved in the assessment and admission process, although this could not be verified, as the registered manager was not available during the inspection. The current fees range from £2226.70 to £2298.76 per week. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Care plans are in place, outlining needs in order that these can be met, however plans must be reviewed, and updated with the people who use the service to ensure needs are being met. The people who use the service make decisions in everyday life, giving them choice. The people who use the service are enabled to take risks, to promote independence. EVIDENCE: The support plans two people who use the service were viewed. Each person continues to have a ‘personal file’, a ‘daily use file’ and ‘financial file’. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 11 Photographs of individuals are included within both the personal file and daily use file. The daily use file continues to outline how individuals communicate, the support required with personal care, with moving and handling and with meals. Information within the file highlights the individuals likes and dislikes, key information on health and the support required when communicating through specific behaviours. Whilst information was available dates of implementation and review were either outdated or not apparent. All files should be reviewed to ensure up to date information is available to support the people who use the service. The personal file outlined things that are important to individuals, family involvement, cultural, religious, and ethnic needs, getting up and going to bed routines and involvement in housekeeping tasks. Support plans clearly indicate how people communicate their needs and choices through sounds and gestures. Staff were respectful and engaged people in daily tasks when possible. The home has advocacy involvement who continue to facilitate service user meetings and minutes of those meetings were seen which support this. Care/support plans refer to the level of support required with finances and families and the organisation act as appointee for individuals as required. A series of risk assessments are available to support individuals, which include an indication of the risk and a management plan to reduce the risk. Risks assessments have been reviewed appropriately. The home continues to have a moving and handling risk assessment for one individual, which was up to date. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There is a limited range of purposeful activities on offer. Individual interests, and choices are not supported on a regular basis, preventing people from trying new experiences and taking part in activities that they enjoy. Family involvement continues to be supported and encouraged. Daily routines do not always promote service user involvement and independence which potentially could prevent people who use the service from been given responsibilities in their daily lives. Meals and menu planning are appropriately managed, ensuring that nutritional needs are met. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 13 EVIDENCE: None of the people who use the service attends college or work placements. The ‘lifestyle plans’ of the people who use the service include a weekly activity programme based upon likes and dislikes. The plans included descriptive accounts of how to communicate with a person to ensure that they are happy to engage in an activity e.g. “I like to be involved in making decisions and choices, and will respond by smiling and laughing and making chuckling noises, If I am not interested I will propel myself away from the situation.” The complex needs of the people who use the service means that lifestyle choices have been made in consultation with individuals, their family members or representatives, family members signing reviews and additions to plans. Lifestyle plan/weekly activities for one individual included household tasks e.g. ‘Tidy own room & do own laundry’, but the majority of information relates to personal activities, ‘ Gateway club, walking programme, hydrotherapy, multisensory session, bank/personal shopping/ food shopping at Tesco’. The plan also indicates that the individual “likes music a lot”. For another person likes were detailed as ‘swimming/hydrotherapy, disco music/lights, going for a walk, parties/social club/meeting people…travel/train, theatre/musical shows/cinema, meals out, musical therapy, bus rides, pub…’ The home continues to maintain an individual monthly record of activities that have taken place. The records for March and April indicated that people who use the service go for lunch out, walks to the village and rides in the minibus, listen to music, watched TV, in the house, cooked with staff, shopping at Tesco’s, went for a ride and to B & Q. The previous inspection highlighted that the records indicate that there are a limited variety of activities on offer, and this clearly remains an issue as activities offered are repetitive and offer very little variety. Personal preferences added into lifestyle plans e.g. going to a football/rugby game, going to see live music haven’t been actioned. The activities do not appear to be tailored to individuals’ choices and interests. Whilst the inspector acknowledges that staff make every effort to ensure people are doing something recognition must be given to individual preferences. Staff stated that there are limitations to supporting people on an individual basis due to only two members of staff on duty, being spontaneous Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 14 is not possible. Additional activities have to be planned to ensure additional staffing is provided. This was highlighted as an issue at the previous inspections. The manager should ensure that people are supported to participate in activities, which relate to their personal preferences on a regular basis. The people who use the service continue to be offered an annual holiday. The home has it own transport. People who use the service are on the electoral roll but do not vote, as staff would have to support them in making those decisions. The home has no people who use the service from a specific ethnic minority background. Support plans indicate individual’s involvement with specific tasks for example housekeeping, laundry, and involvement in cooking and making drinks, which would promote their independence and choices. However, people were not observed to be involved in the tasks outlined within their plans. People who use the service have three meals a day and records are maintained to confirm this. There is good variety in the weekly menu and a second choice of meal is offered and can be made available. The menu plan is agreed weekly. Service user plans include information on individuals likes and dislikes which includes foods and staff confirmed that they know what individuals like and don’t like. One individual requires assistance from staff with their meals; appropriate aids and equipment are made available as required. Staff confirmed that guidance from a dietician is available when required. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Systems are in place to ensure that people who use the service personal care and healthcare needs are met and monitored which promotes their well-being. However, some aspects of individuals healthcare needs are being undertaken by staff who have not been appropriately trained therefore the safety of the people who use the service cannot be assured. Improvements have been medication practices that ensure the safety of people who use the service. EVIDENCE: The care/support plans of people who use the service outline the level of support required by individuals in meeting their personal care needs. A moving and handling assessment continues to be in place as required for one individual. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 16 Personal support is provided in private in bedrooms and bathrooms. Times for getting up and going to bed are flexible. Specialist equipment is available as required. A staff member stated that people who use the service have access to specialist support as required, but records did not fully support this. Correspondence within one individuals file indicated that an appointment with a doctor to review the person’s epilepsy needs had been forgotten, although seizure record charts had been forwarded to the doctor with a letter of apology. No further correspondence or review was evident; therefore it was unclear as to whether the individual’s needs had been appropriately reviewed. The inspector acknowledges that there are descriptive seizure charts available that have been completed by staff and that the majority of healthcare appointments with outcomes are recorded. However, it remains important that all aspects of an individual healthcare needs should be followed up to ensure their welfare is maintained. An issue for concern was recorded within the staff message book and relates to the needs of an individual. A message addressed to the manager and the person’s key worker on the 04.03.07 stated “Was not able to cut X’s feet nails…Could you look into, please to arrange chiropodist, thanks.” No record of an appointment with a chiropodist was apparent. Records indicate that staff are cutting finger and toe nails. The individuals care/support plan clearly states, “I attend podiatry. Care must be taken when cutting my nails as skin is close to the nail. Staff cut my finger nails and podiatry my toes.” The support plan was dated as 29. 11. 02, with a review date of the 08.09.05. Guidelines within the home’s Health and Safety manual regarding foot care describe the circumstances in which staff can undertake foot care and only after appropriate training. Staff members stated that they have not received training regarding foot care but have been cutting both the hand and foot nails of people who use the service. This puts people at risk. Staff also stated that podiatry services are “stretched” and are unable to provide appointments to the people who live at Sunnybrook Close. A review of individual need must be undertaken and recorded to ensure that the most appropriate service is provided and that support plans are up to date. Staff must be appropriately trained, in line with the organisations policy/guidelines to ensure the health, safety and welfare of people who use the service. All of the people who use the service have a nominated key and link worker at the home. Service user plans outline likes, dislikes and routines. All of the people who live at the home are registered with a local doctor. Specialist support continues to be provided from a wide range of professionals within a community learning disability team. Individual records are generally Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 17 maintained of all healthcare appointments, which include the outcome of the visit. Staff remain responsible for administering medication. The medication is stored in a locked cupboard in individual’s bedroom and excess stock is stored in a large locked medication cupboard in the bathroom. The medication administration records seen showed no gaps in the administration of medication. The home continues to have appropriate systems in place for the ordering, receipt, storage and disposal of medication. The home has written guidelines in place on the use of all as prescribed medication. Staff members stated that staff are inducted and assessed in medication procedures prior to administering medication. Initial medication administration training is provided at Head Office with a competency assessment completed with the manager. This could not be verifies as training records were unavailable, however the action plan received following the previous inspection states that update have been provided to staff. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A complaints procedure is in place and which allows for complaints to be investigated and responded to within the required timescale, which indicates that concerns are acted on to benefit people who use the service. Policies and procedures are in place to ensure the protection of people who use the service. Update training on adult protection/safeguarding adults has been provided for staff. EVIDENCE: The home has a complaints procedure in place, including a pictorial version for people who use the service. Staff stated that people who use the service and their representatives have been given the opportunity to view the complaints procedure to ensure they are aware of the process if issues arise. The home has a complaints and a compliments log, although this could not be viewed as the files are within a locked filing cabinet with only the manager having access to the information. No formal complaints have been received at the CSCI since the last inspection. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 19 The home has a protection of vulnerable adults policy and confidential reporting policy. The staff spoken with remain clear of their role in reporting bad practice and any issue of concern. The previous inspection highlighted that some staff had not had updates in protection of vulnerable adults/safeguarding training. An action plan received after the previous inspection states that adult protection training has undertaken, this could not be verified, as training records were unavailable, however a member of staff was able to confirm attendance at the training. All of the people who use the service continue to have a cash box in their bedrooms and can keep a maximum of £20 at any one time. Records are kept of all transactions and the balance checked by two staff daily. The senior reconciles and checks the expenditure against the bank statement on a monthly basis. Regulation 26 reports indicate that a service manager checks one people who use the service money and financial records each month. None of the people who use the service require support or physical intervention for challenging needs. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28 & 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home is generally clean, homely and systems are in place to maintain this to provide a safe environment for people who use the service. The lack of development within the garden restricts use for the people who use the service and does not allow all recreational areas to be used. The garden needs to be developed to provide options for all recreational areas to be used. EVIDENCE: The home continues to be accessible to people who use the service with a ramp to the entrance to the home. The home is homely, welcoming, well equipped and generally well -maintained. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 21 The bedrooms and communal areas are furnished to a high standard and bedrooms are individually personalised. A storage cupboard to store aids, equipment and spare stock is available within the hallway. The home has a private, secure rear garden. At three previous inspections it was noted that plans were in place to develop the garden with a sensory and a shaded seating area. It was disappointing to again note that the garden remains undeveloped, however it was tidy and the patio area was usable. The lack of development within the garden restricts use for the people who use the service and does not allow all recreational areas to be used. Staff were unable to confirm whether the work will be started. Staff are responsible for maintaining the cleanliness of the home and systems remain in place to support this. The home was generally clean and free from odour. The home has a separate laundry and a washing machine with sluicing facilities. Members of staff confirmed that Health and safety policies are available but they were not viewed at this inspection. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The skills of the staff team could not be adequately assessed due to training records being unavailable although interaction with people who use the service was observed to be positive and respectful. Information regarding recruitment practice was unavailable, therefore confirmation that safe recruitment practices are in place could not be made; this potentially puts people who use the service at risk. Regular supervision is offered to all staff providing an opportunity to review practice, however records to confirm that the sessions had taken place were not available. EVIDENCE: Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 23 The assessment of staff skills was undertaken through observation only as records regarding training, including specialist training were not available for inspection. Staff were accessible to people who use the service for the majority of the time. Interaction was positive and respectful, although at times communication and engagement with people was limited, but there clearly has been an improvement since the last inspection. Staff should always be aware of the need to engage and communicate with people when household and daily routines are being completed. The inspectors request to see staff recruitment and training files could not be met as the files are deemed confidential with only the manager having access to the information. The manager was not available on the day on inspection. Requirements made at the inspection visits of the 12th December 2005 and 6/7th June 2006 identified a number of omissions and failings in relation to recruitment information and mandatory and specialist training. The previous inspection identified that “None of the staff files seen contained all of the schedule 2 information that they are required to make available.” It was also identified that “the home had no information on the bank staff who work shifts at the home. A requirement was made at the last inspection that staff files must be updated with the information as outlined under Schedule 2 and Schedule 4(6). This has not been complied with.” The action plan sent to the CSCI following the previous inspection states that “Required information to be placed in staff files”. As staff files could not be viewed a judgement could not be made. The manager and organisation must ensure that information should be made available for inspection, a requirement is made. The inspector acknowledges that personal information needs to be held in a confidential manner. The organisation must ensure that the manager can demonstrate that all aspects of the regulations regarding the employment of staff are met. A checklist that is signed by the manager must be held at the home, which confirms that all required recruitment information/documents are present on file. The home continues to use agency staff to cover on average 2 shifts per day, although this can vary from 1 up to 3 shifts. The agency staff member on duty during the inspection had been working at the home for 10 months and had developed a good working relationship with both people who use the service and other staff members. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 24 A member of staff stated that two people had recently been recruited in an attempt to reduce the number of agency shifts required, but vacant posts remain at the home Confirmation has been received from the agency that individuals have two references on file and their Criminal Records Disclosure number. The home has a copy of photo identification for agency staff. A request to see staff training files (including agency staff) could not be met, as the files are within a locked filing cabinet with only the manager having access to the information. A review of the requirements made from the last inspection could not be undertaken, although the action plan received after the previous inspection states that mandatory training and additional training in supporting people who use the service to make choices, medication administration, adult protection and storage of hazardous materials has been undertaken, this could not be verified, although a member of staff was able to confirm attendance at adult protection training. The organisation and manager must ensure that information required for inspection is made available. Staff members confirmed that supervision is undertaken regularly. Supervision sessions are identified upon the staffing rota and this suggests that regular supervision is undertaken, although records to confirm that the sessions had taken place were not available. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home does not have a registered manager, although a manager is in post, which has brought stability and consistency to the home, benefiting people who use the service. The organisation continues to carry out monthly monitoring of the service and the quality audit tool is available to ensure that a high standard of care is being maintained to benefit people who use the service. Health and safety practices have improved reducing the risks to people who use the service. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 26 EVIDENCE: The home continues to not have a registered manager in post, however a manager was recruited to the home in September 2006. The home has been without a registered manager since June 2005 An application for registration must be submitted to the CSCI to ensure that responsibility for the day-today and ongoing development of the service is undertaken and managed effectively. The service manager continues to oversee the service, although clear management responsibility has been given to the manager. Staff at the home confirmed that the presence of a permanent manager has brought stability and consistency to the home. The manager was described as being open and accessible welcoming the views and assistance of the people who use the service and staff members. The home has copies of regulation 26 reports available, regular unannounced visits are made to the home by the service manager. Information relating and belonging to people who use the service is held in a locked cupboard at all times ensuring security and confidentiality. Staff at the home continue to carry out quarterly health and safety checks. The water at the home is thermostatically controlled and water temperature checks are carried out weekly. Water temperatures are maintained at a safe level. The health and safety records viewed are well maintained and up to date. The home has fire records in place, which confirms that the fire call points are checked weekly and the emergency lighting is checked monthly. A fire risk assessment is available; fire equipment is serviced as required. ‘Shift planners’ are used to ensure a list of tasks is completed for both day and night shifts. The planners include support needs of people who use the service and domestic tasks; staff are expected to tick and initial when a task has been completed. The night planner has a significant number of domestic duties to be completed but support needs of individuals are included e.g. ‘Clean sinks and buff taps, clean machines down, tidy COSHH cupboards and clean outside, sweep and mop floor, to be changed as and when necessary/please tick when changed (the names of the people who use the service are then listed), wheelchairs, to be checked and wiped down nightly, Residents’ care, Please check all Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 27 residents on a regular basis, clean and change pad and bedding whenever necessary, night time diaries to be completed….’ By including the needs of people who use the service in a domestic list of duties questions how people are valued. Individuals care/support plans should guide staff as to how people need to be supported both during the day and night. The inspector acknowledges that the list provides a prompt and can act as a management tool to ensure staff are fulfilling their duties but thought should also be given to how this values the people who use the service. The previous inspection highlighted that hazardous cleaning materials were left out in an unlocked cupboard; this has now been addressed with staff. All hazardous materials are in a locked cupboard. The home continues to have an occurrence file, which includes accident, and incident reports. Staff are now aware that they must report any event that affects the well being of people who use the service to the Commission. Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 1 X 3 X 2 3 X Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? No 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 YA13 Regulation 16 (m) & (n) Requirement The organisation must ensure that activities identified by the people who use the service can be facilitated on a regular basis to ensure their identified needs and preferences are met. Timescale for action 31/08/07 2. YA19 13 (1) (b) 3. YA28 23 (2) (o) 4. YA37 8 (1) (a) The organisation must ensure 31/08/07 that staff are appropriately trained to carry out foot care tasks. This must be conducted in consultation with appropriately trained professionals and in line with the organisation policies and procedures to minimise the risk to the people who use the service. The organisation must provide 30/09/07 external recreational space that can be used safely by all of the people who reside at the home. The manager must submit an 31/08/07 application for registration with the correct fee to the CSCI to ensure the protection of the people who use the service and that the day-today and ongoing development of the service is managed effectively. . DS0000028528.V331843.R01.S.doc Version 5.2 Page 30 Sunnybrook Close (6) 5. YA41 17 (3) (b) The organisation must ensure that all records are made available for inspection to validate that all legal obligations are being met and to ensure the health, safety, and welfare of people who use the service and of staff. 31/08/07 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 All files relating to the needs of people who use the service should be reviewed to ensure up to date information is available and should include a date of implementation and review. The manager should ensure that all aspects of individuals’ healthcare needs are reviewed with outcomes recorded appropriately to ensure that needs are being met. 2. YA19 Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sunnybrook Close (6) DS0000028528.V331843.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!