Inspection on 06/06/06 for Sunnybrook Close (6)

This inspection was carried out on 6th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Sunnybrook Close (6) 18/04/07

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 Mrs Maureen Richards Unannounced Inspection 6 & 7th June 2006 12:30 th Sunnybrook Close (6) DS0000028528.V292773.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 Sunnybrook Close (6) DS0000028528.V292773.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. Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 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 Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th December 2005 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 service users. The home is run and managed by Hightown Praetorian and Churches Housing. Sunnybrook Close provides single room accommodation for all service users 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.V292773.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over a day and a half. The key National Minimum Standards for younger adults were inspected and the progress in meeting requirements from the previous inspection was evaluated. No comment cards were received from service users, relatives or professionals involved with the home in respect of this service. The organisation has made attempts to recruit into the manager vacancy and a manager from another service is overseeing the home two days a week. However a number of requirements form the previous inspection has not been complied with and the organisation must ensure that these are now addressed as matter of urgency. The Commission is considering what action is necessary in relation to noncompliance with Regulations. What the service does well: What has improved since the last inspection? What they could do better: Service user plans must be further developed to include all support plans and to contain more specific guidelines for staff on how service users medical conditions are to be managed. Service users plans should indicate service users involvement. Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 6 Records must be maintained of how decisions and choices are made by individuals. Risk assessments must be kept updated and reviewed. The range of activities on offer must be developed and activities should be meaningful for individuals. Service users should be supported to become more involved in activities of daily living and as outlined in their service user plans. Alternative meal choices should be made available and records must be maintained of how meal choices have been made. Some improvements are required to medication practices. The frequency of adult protection training must be increased and made available to staff. Improvements are required to the garden to make it more accessible and suitable for service users. The majority of the staff team do not have specialist and mandatory training. The home does not have the required records available to confirm if all staff have been properly recruited. All staff do not receive regular and recorded supervision. The home does not have a registered manager, which has lead to inconsistency in the management of this home. Some health and safety practices are unsafe and an immediate requirement was served to address a risk that posed an immediate risk to service users. 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. Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The organisation has an admissions procedure in place which indicates that systems are in place to ensure that prospective service users are fully assessed prior to admission to ensure that the home can met their needs. EVIDENCE: The home has had no new admissions since being registered. The organisation has a policy and procedure in place that outlines the steps to take prior to admission, on admission and post admission and indicates that the registered manager is involved in the assessment and admission process. The policy makes reference to the need to complete a referral form. This was not available in the home and therefore it was not assessed if this is in line with standard 2.3. The senior confirmed it is accessible on the public drive for when required. Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 9 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 is poor. This judgement has been made using available evidence including a visit to the service. Some service user plans lack specific information and support plans on aspects of care for individuals, they do not indicate evidence of service user involvement in their development which potentially does not provide continuity of care for service users. Systems are in place to involve service users in decisions however records are not consistently maintained to indicate how some decisions are made. Risk assessments are not kept updated and reviewed which potentially puts service users at risk. EVIDENCE: All three service user plans were viewed at this inspection. Each service user has three files, a daily use file, a personal file and a financial file. Service users daily use file and personal file contain a photograph. Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 10 The daily use file outlines how individuals communicate, the support required with personal care, with moving and handling and with meals. It outlines the individuals likes and dislikes, key information on health and the support required when communicating through specific behaviours. Service user plans included support plans, however in one service user plan references were made to support plans which were not filed in the service users file. 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. A recommendation was made at the previous announced inspection that service user plans should indicate evidence of service user involvement or an indication on how the information was obtained which involved the service user. None of the service user plans indicated service users involvement or any indication how the information was obtained or if it was discussed and made known to service users. All of the service users plans made reference to a medical condition but this information was not detailed and specific as to how staff manages a medical crisis. One of the service user plans indicated that the individual enjoyed the church service but did not indicate where and when the service takes place or indicate if the service user is supported to attend. Service user plans include guidelines from other professionals involved in individuals care. A recommendation was made at the previous inspection that guidelines developed from information supplied from other health professionals should include a date of implementation and review. Some of the guidelines seen in service users files did not indicate when implemented, a date of review and no indication if those guidelines were still relevant for those individuals. None of the currant service user group communicates verbally and service users plans indicate how those individuals communicate their needs and choices. It was noted during the two days of the inspection that there was limited communication by some staff with service users whilst supporting them with their daily tasks. The home has advocacy involvement who facilitates service user meetings and minutes of those meetings were seen which support this. Service user plans make reference to the level of support required with finances and families and the organisation act as appointee for individuals as required. Service user plans included a series of risk assessments, which included an indication of the risk and a management plan to reduce the risk. The action plan for risks was not easily accessible in some service users files. The risk assessment on the management of a medical condition lacked detailed information for staff on the management of this risk. One service user plan indicated an advocate’s involvement in the review of risk assessments. The risk assessments in the other two service users files were overdue for review. Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 11 The home has a moving and handling risk assessment for one individual, which was up to date. Sunnybrook Close (6) DS0000028528.V292773.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, 15, 16 & 17 Outcome in this area is poor. This judgement has been made using available evidence including a visit to the service. There is a limited range of purposeful activities on offer to service users which takes account of their individuals interests and choices which prevents them from trying new experiences and potentially could prevent them from taking part in activities that they enjoy. Family support and involvement is supported which benefits the service user. Daily routines do not promote service user involvement and independence which potentially could prevent service users from been given responsibilities in their daily lives. Meals on offer are varied but do not indicate an alternative or how service users made a choice of meal, which could result in service users being served meals that they do not want. EVIDENCE: Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 13 None of the current service user group attends college or work placements. All of the service user files include a weekly activity programme, which indicate that individuals attend for specific one to one hydrotherapy sessions. The senior has recently accessed a story telling group for two individuals and the activity programme indicate that in house multi sensory sessions are made available to service users. One service users attends the gateway club on a weekly basis. The home maintains an individual monthly record of activities that have taken place. The records for May and June indicate that service users go for lunch out, walks to the village and rides in the minibus. The records indicate that there is a limited variety of activities on offer. The activities do not appear to be tailored to individuals’ choices and interests and no record is maintained to indicate how the choice of activity was made. In some cases the activities do not have a purpose for example minibus rides and a trip to the car wash. Two service users recently went to a gig at the local public house and feedback from staff and daily records indicate that they both enjoyed this. The range of activities on offer must be developed on and tailored to individuals’ needs, choices and interests. Records should be maintained as to how those choices are made. The rota indicates that there is two staff on duty at all times and extra staff can be provided for specific planned activities. One service user’s activity record indicates two occasions where the service user could not go for a walk, as there was no staff available. A recommendation was made at the previous inspection that the service manager must ensure that all staff facilities activities and that if an activity is unable to take place a record is maintained as to why. The record seen indicated staff were not available but did not go on to explain why staff were not available as the rota indicated that there was two staff on duty on both shifts. This must be monitored. The service users are scheduled to go on an annual holiday in July. The home has it own transport. Service users are on the electoral roll but do not vote, as staff would have to support them in making those decisions. The home has no service users from a specific ethnic minority background. The home has a visitors policy which indicates visitors are welcome at the home. Service user plans outline family and friends’ involvements in individuals care and include dates of family birthdays and other celebrations so that the service user can be supported in contributing to those celebrations. A card from one family expressed their thanks to staff for making a visit to the home special for them and their relative. No comment cards were received from relatives. Service users plans indicate service user involvement with specific task for example housekeeping, laundry and involvement in cooking and making drinks, which would promote their independence and choices. However service Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 14 users were not observed during the inspection in being involved in those tasks as outlined with their plans. The senior confirmed that service users have a key to their bedroom and front door but were not observed being supported to use it. Service users were not observed being supported or encouraged to open the front door to visitors. Service user plans make reference to the level of support required by individuals in managing their post. Service users are called by their preferred name as outlined in service user plans. Service users can choose when or if to join an activity and this is made known to staff by their refusal to put shoes or coats on to go out for an activity. Service users have unrestricted access to areas of the home but require supervision when accessing the garden and outside of the home. Service users have three meals a day and records are maintained to confirm this. Service users have a good variety in their weekly menu but there is no indication of a second choice of meal being made available to service users. The menu plan is agreed weekly and there was only two occasions where records were maintained to indicate how service users made their choice of meals. Service user plans include information on individuals likes and dislikes which includes foods and the senior confirmed that staff know what individuals like and don’t like. Records of how choices are made should be maintained to support this. Service users are encouraged to go food shopping with staff. One service user require assistance from staff with their meals and appropriate aids and equipment is made available for individuals as required. The senior confirmed that the home is able to access dietician input for individuals as required and meals are developed under guidance form the dietician. Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Outcome in this area is adequate. This judgement has been made using available evidence including a visit to the service. Systems are in place to ensure that service users personal care and healthcare needs are met and monitored which promotes their well-being. Improvements are required to medication practices to ensure the safety of service users. EVIDENCE: Service users plans outline the level of support required by individuals in meeting their personal care needs. A moving and handling assessment is in place as required for one individual. Personal support is provided in private in bedrooms and bathrooms. Times for getting up and going to bed are flexible and service users daily and night records indicate this. Service users have access to specialist equipment as required. The team leader confirmed that service users have access to specialist support as required and service user healthcare appointment records supports this. Service users have access to general nursing care through the General Practitioner. All of the Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 16 service users have a nominated key and link worker at the home. Service user plans outline service users likes and dislikes and routines. All of the service users are registered at a local General Practitioner surgery. Service users access community podiatry, opticians and dentists. Service users have input from a wide range of professionals based at Manor House Hospital. Individual records are maintained of all healthcare appointments, which include the outcome of the visit. Staff are responsible for administering service users 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 although the staff meeting minutes indicates discussion on medication errors which the team leader advised was medication not being signed for. The home has systems in place on the ordering, receipt, storage and disposal of medication. A record of disposal of medication is kept and the home keeps a monthly record of expiry dates of non-blistered medication. All service users medication records were viewed. Some medication administration records indicated changes to medication, times or medication had been discontinued. Staff should ensure that any changes to medication is countersigned by two staff in line with the pharmaceutical guidelines and where medication has been discontinued this should be taken off the medication administration record or reference made on the medication administration as to when and who discontinued the medication. The home has written guidelines in place on the use of all as prescribed medication. During the inspection it was noted that excess stock of Gaviscon was not stored in a locked cupboard and one service user’s medication had been dispensed and was left unattended on the dining room table. This must be addressed with staff. New staff are inducted and assessed in medication procedures prior to administering medication. A completed induction was seen. The medication assessment was incomplete even thought this staff member was responsible for administering medication. A requirement was made at the previous inspection that the service manager must ensure that all staff responsible for administering medication have been assessed and are deemed competent to administer medication. This has not been complied with. Training records seen indicate that some staff have care of medicines training. Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 17 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 Outcome in this area is adequate. This judgement has been made using available evidence including a visit to the service. A complaints procedure is in place and complaints are investigated and responded to within the required timescale, which indicates that concerns are acted on to benefit service users. Policies and procedures are in place to ensure the protection of service users. This needs to be supported by more regular updates on adult protection training for staff. EVIDENCE: The home has a complaints procedure in place, which was not viewed at this inspection. Service user plans include a pictorial complaints procedure. A recommendation was made at the previous inspection that the pictorial complaints procedure should be updated and re explained to service users. Service users records indicate that this has not been done. The home has a complaints and a compliments log. The complaints log indicates that there has been one complaint since the last inspection, which was investigated and responded to appropriately. The home has a protection of vulnerable adults policy and confidential reporting policy, which was not viewed at this inspection. The staff spoken with were clear of their role in reporting bad practice and any issue of concern. Training records seen indicate that some staff have not had updates in Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 18 protection of vulnerable adults training and updates in this training must be made available on an annual basis and not as a one off. All of the service users 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 service users money and financial records each month. None of the service users money was checked against the records at this inspection. None of the current service user group present with physical and verbal aggression. Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 19 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 Outcome in this area is adequate. This judgement has been made using available evidence including a visit to the service. The home is generally clean, homely and systems are in place to maintain this to provide a safe environment for service users. The garden now needs to be developed to complement this. EVIDENCE: The home is accessible to service users with a ramp to the entrance to the home. The home is homely, welcoming, well equipped and generally well maintained. The bedrooms and communal areas are furnished to a high standard and bedrooms are individually personalised. The home does not have a programme of decoration in place but areas of the home have recently being decorated and new curtains have been purchased for the sitting room and patio door. However some of the woodwork and internal doors are showing signs of wear and tear and damage from wheelchairs. A recommendation was made at a previous inspection that the organisation should provide the home with a storage cupboard to store aids, equipment and spare stock. This has now being fitted. Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 20 The home has a private secure rear garden. At 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 note that the garden remains undeveloped and in parts overgrown. The senior had arranged for contractors to come in to give her a quotation to develop the garden and it is hoped this work will now get underway to benefit service users. Staff are responsible for maintaining the cleanliness of the home and systems are in place to support this. The home was generally clean and free from odour. Carpets in two of the bedrooms were stained and this must be addressed. The home has a separate laundry and a washing machine with sluicing facilities. Health and safety policies were not viewed at this inspection. Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 21 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, 34, 35 & 36 Outcome in this area is poor. This judgement has been made using available evidence including a visit to the service. The majority of the staff team do not have the necessary skills and specialist training to meet service users needs. The home does not have the required information available to confirm that safe recruitment practices are in place, which potentially puts service users at risk. Staff do not have the required mandatory training, which could affect the safety and well being of service users. All staff do not receive regular supervision which could result in them being unsupported in their roles which potentially could affect the delivery of care to service users. EVIDENCE: Staff are accessible to service users. It was observed over the two days of the inspection that some staff did not communicate or engage with service users whilst supporting them with their daily routines. Further training is required to promote this. Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 22 Two out of the seven permanent staff team have specialist training in learning disability awareness, three out of the seven staff have epilepsy training but two of those staff had that training in 2002. The home has two staff with a National Vocational Qualification and a third staff member is due to finish this qualification. Three staff have recently commenced their National Vocational Qualification. Six staff recruitment files were viewed at this inspection. The files seen contained confirmation of Criminal Records Bureau checks and disclosure numbers and two references. The Criminal records Bureau disclosure number for the newest staff member had been faxed over to the home the previous day, which was day one of the inspection. All of the staff files contained a copy of the application form but the application form on the senior’s file was not for that post. One of the staff files seen contained a medical fitness. Two of the files contained a copy of their driving licences and copy of photo driving licence. One staff file contained a copy of the individual’s birth certificate. None of the staff files seen contained all of the schedule 2 information that they are required to make available. 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 home uses agency staff to cover shifts. Confirmation has been received from the agency that individuals have two references on file and their Criminal Records Disclosure number. The home has obtained a copy of photo identification for some agency staff. The agency staff member on duty during the inspection did not have her photo identification on her on day one of the inspection. She brought this in on day two of the inspection and it was out of date. The organisation has a detailed and comprehensive in house induction record. Some areas of inductions for new staff to the home need to be signed off and as outlined under standard 20 the assessment of medication was incomplete. The home has introduced written confirmation of induction for bank and agency staff. The training records indicate that only two of the staff team have all of the required up to date mandatory training and there are no training records available at the home for bank staff to establish if they have the required mandatory training. A requirement was made at the previous inspection that the organisation must ensure that all staff including bank staff have the required up to date mandatory training. This has not been complied with. The home uses agency staff to cover shifts. The agency information for individual staff includes a statement to say that all staff have mandatory training as indicated on their training card. The agency staff member on duty confirmed that she had no training record card supplied to her by the agency. The organisation must ensure that agency staff supplied to the home have the Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 23 required mandatory training and any specialist training required in this service to enable them to work on their own. A requirement was made at the previous inspection that the organisation must ensure that staff receive regular supervision. The supervision records available confirmed that staff do not receive regular supervision however two of those individuals were on duty during the inspection and confirmed that they have had regular supervision but the records have not been maintained to support this. Other staff have not had regular supervision. This requirement has not been complied with. Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 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 Outcome in this area is poor. This judgement has been made using available evidence including a visit to the service. The home does not have a registered manager which results in the home not been managed consistently to benefit service users. The organisation carries out monthly monitoring of the service and the quality audit tool is being developed to ensure that a high standard of care is being maintained to benefit service users. Some health and safety practices are unsafe and potentially put service users at risk. EVIDENCE: The home does not have a registered manager. The home has been without a registered manager since June 2005 despite attempts to recruit into this vacancy. Further interviews were scheduled to take place the week following Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 25 the inspection. A manager from another home is currently overseeing the home two days a week. The senior has two administration days per week to enable her to take on management responsibilities. The service manager is overseeing the service and is present at the home on a regular basis during the week. Staff at the home confirmed that the different management styles is confusing and does not allow for the home to be managed in a consistent way. There is an number of requirements from the previous inspection not complied with and in the absence of a registered manager the organisation must ensure that those are now addressed and that future requirements are complied with. The home has copies of regulation 26 reports available. The service manager confirmed that the organisation is presently developing it’s quality assurance tool and this is planned to be piloted from July 2006. The organisation is reminded to send a summary of the findings of the quality audit for the home to the Commission. Standard 41 was not assessed at this inspection. A requirement was made at the previous inspection that information pertaining to service users must be kept secure and confidential. On day one of the inspection the message book and the diary which both included information pertinent to service users was left out on top of a cupboard and accessible to service users and visitors to the home. This must be addressed with staff and monitored. All staff do not have the required mandatory training as outlined under standard 35. Staff at the home carry out quarterly health and safety checks, which was due to be completed. The water at the home is thermostatically controlled and water temperature checks are carried out weekly. The records indicate that some water temperatures have been reading above the required safe level for a period of time. On day one of the inspection this was reported to maintenance and attended to. Staff carry out a weekly showerhead flush and records are maintained to confirm this. The home has records in place to confirm that the first aid boxes are stock checked. However the records indicate this was last done in February 2005 and the frequency of this check should be increased. The home has fire records in place, which confirms that the fire call points are checked weekly and the emergency lighting is checked monthly. The emergency lighting records for April and May were ticked to confirm that they had been done but had not been signed. The home had a pan fire in February 2006 and an evacuation was carried out and the fire brigade called. The last recorded fire drill was in December 2005. The home has records in place to confirm that the fire equipment was serviced in May 2006. The home has a fire risk assessment, which was reviewed in December 2005. The home has task risk assessments in place and a requirement was made at the previous inspection that a risk assessment was to be carried out to indicate Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 26 if access to rubber gloves, washing powder and softener poses any risks to service users and action to be taken to minimise the risk. This has been complied with. The senior confirmed that an environment health and safety assessment was carried out in January 2006 but the documentation was not available to support this. There was e-mail correspondence to maintenance to address issues picked up from the health and safety assessment and some issues had still not being resolved. The home has a certificate to confirm that the gas safety check was carried out in November 2005. The portable appliances were up to date but there was no report available to confirm this. The home has COSHH data sheets in place. During the tour of the environment it was noted that hazardous cleaning materials was left out in an unlocked cupboard. This must be addressed with staff. The home has an occurrence file, which includes accident, and incident reports. A service user recently had a fall, which was not reported to the Commission. The accident /incident flow chart do not include notification to the Commission. The organisation must ensure that staff report any event that affects the well being of service users to the Commission. The accident report form indicates that staff lifted the service user without using the hoist. This must be addressed with the individuals concerned and is not in line with Moving and Handling regulations. The home has a portable hoist and specialist bath. The servicing records indicate that both pieces of equipment were last serviced in April 2005 and were overdue for a service. An immediate requirement was made to address this. Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 1 X 3 X X 1 X Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 28 Are there any outstanding requirements from the last inspection? Yes 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 YA6 Regulation 15 Requirement Service user plans must include support plans as referred to and specific guidelines for staff on the management of medical conditions. Records must be maintained as to how individuals make choices and decisions in relation to aspects of their daily lives for example meals and activities. All risk assessments must be kept updated and reviewed. The range of activities on offer must be developed on and tailored to individual’s needs, choices and interests. Timescale for action 31/07/06 2 YA7 12 31/07/06 3 4 YA9 YA13 13 16 31/07/06 30/09/06 5 YA20 18 6 YA20 13 7 YA20 13 The service manager must 31/07/06 ensure that all staff responsible for administering medication have been assessed and deemed competent to administer medication. A record must be maintained to confirm this. (Previous timescale of the 31/01/06 not met) The organisation must ensure 31/07/06 that changes made to medication administration records are in line with Pharmaceutical guidelines. The organisation must ensure 31/07/06 DS0000028528.V292773.R01.S.doc Version 5.1 Page 29 Sunnybrook Close (6) 8 9 YA23 YA32 13 18 10 YA34 19 11 YA35 18 12 YA36 18 13 YA41 17 14 YA42 37 15 YA42 18 16 YA42 23 that staff follow procedures in relation to administration and storage of medication. Updates in adult protection training must be made available to staff. The organisation must ensure that staff are trained to communicate and interact with service users whilst supporting them with their daily tasks. Staff files must be updated with the information required as outlined under Schedule 2 & 4 (6). This information must be made available for all bank staff also working at the home. (Previous timescale of the 28/02/06 not met) The organisation must ensure that all staff including bank and agency staff have the required up to date mandatory training (Previous timescale of the 28/02/06 not met) The organisation must ensure that staff receive regular supervision and records must be maintained to support this. (Previous timescale of the 28/02/06 not met) Information pertaining to service users must be kept secure and confidential. (Previous timescale of the 31/12/05 not met) The organisation must ensure that staff report any event that affects the well being of service users to the Commission. The organisation must ensure that individual staff work in line with Moving and Handling regulations The organisation must ensure that the portable hoist and specialist bath is serviced and DS0000028528.V292773.R01.S.doc 30/09/06 30/08/06 31/07/06 31/08/06 31/08/06 31/07/06 30/06/06 31/07/06 09/06/06 Sunnybrook Close (6) Version 5.1 Page 30 17 YA42 13 this must be maintained and monitored. All hazardous cleaning materials must be kept secure. 30/06/06 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. Refer to Standard YA6 Good Practice Recommendations Service user plans should indicate evidence of service user involvement or an indication on how the information was obtained which involved the service users. Guidelines developed from information supplied from other health professionals should include a date of implementation and review. The service manager must ensure that all staff facilitates activities and that if an activity is unable to take place a record is maintained as to why. Service users should be supported to get involved in all aspects of their daily lives and as outlined within their service users plans. The pictorial complaints procedure should be updated and re- explained to service users. The frequency of the check of first aid boxes should be increased. 2. YA6 3. YA13 4. 5. 6 YA16 YA22 YA42 Sunnybrook Close (6) DS0000028528.V292773.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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. 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