CARE HOME ADULTS 18-65
The Boundary 418 Parrswood Road East Didsbury Manchester M20 9GP Lead Inspector
Steve O`Connor Key Unannounced Inspection 25th April 2006 1:00 The Boundary DS0000021605.V291379.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 The Boundary DS0000021605.V291379.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. The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service The Boundary Address 418 Parrswood Road East Didsbury Manchester M20 9GP 0161 445 0422 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) Mrs Teresa Williams Mrs Joan Elizabeth Ford Care Home 12 Category(ies) of Learning disability (12) registration, with number of places The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. One named service user is aged 65 years or over. Should this service user leave the home the place will revert to the service user category Learning disability (LD). 9th February 2006 Date of last inspection Brief Description of the Service: The Boundary is a home providing accommodation and personal care for 12 adults with a learning disability. It is made up of two semi-detached houses converted into one to form a detached property. The home has a paved area at the front with parking for approximately three cars. The home also has a conservatory and a large rear garden with seating and shaded areas. The garage situated at the rear of the property is used for storage. Accommodation at The Boundary consists of eight single and two double bedrooms. There are two adjoining lounge areas, a kitchen and a large conservatory, which is used as a dining area and for activities. The home is situated in a residential area of West Didsbury, close to public transport routes into the city centre and surrounding areas. A railway station is less than five minutes walk from the home. The area has a good range of all the usual services, including shops, a post office and public houses etc. A large Tesco supermarket and a leisure park is situated less than five minutes walk from the home and there is a corner shop nearby, which is convenient for the people who live there. The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced visit took place on Tuesday 25th April 2006. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS) and was used to decide how often the home needs to be visited to make sure that it meets the required standards. As part of the visit time was spent with the people who use the service, observing how staff work with people, discussions with staff and the manager, assessing relevant documents and files and a tour of the premises. The last visit to the home identified a number of areas that the home needed to improve to meet the NMS. The home had not sent the CSCI an action plan setting out how they were going to address these issues. It was found that progress had been made in several areas with around half of the requirements fully actioned. The remaining issues will be repeated in this report. As a result of the home not meeting a number of requirements that have been outstanding since the last two visits the CSCI intend to take the necessary action to ensure that the registered provider address the issues and meet the standards and requirements. The CSCI had not received any complaints or concerns about the home since the last visit. What the service does well:
If the home has a vacancy to offer a placement then they have the referral system that includes both visiting the prospective person and giving them the opportunity to visit the home. Information about prospective people’s needs would be gathered from a variety of sources and information about the service would be provided to people to help them make decisions. Where they can, people are encouraged and supported to take decisions and makes choices about their day-to-day lives and what they want to do regarding social, leisure and development activities. People can meet in a group or will discuss with staff on an individual basis about the things that affect them and what they want to do. Although the home does rely heavily on the use of dedicated learning disability services, such as college courses, day and drop-in services, they do work hard to find out what activities interest people and find the right service who can offer those activities. People have been encouraged to learn new skills at college and to look ahead at options for work.
The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 6 People’s family and friends are encouraged to be as active and involved in a persons’ life as they both wish. Several people regular go and stay with families and visitors to the home are welcome at any reasonable time. The home had asked peoples’ families to complete a questionnaire on what they thought about the home. The comments were generally very positive about the standard of care their families received. The premises are well decorated, clean in all areas and had a very homely and relaxed feel. There were different communal areas where people can spend time together or in private. What has improved since the last inspection? What they could do better:
People who live in care homes do so for a variety of reasons but generally they need help and support to allow them to live as independently and safely as possible. Care homes must show that they understand what help people need and so they are required to develop individual care plans that sets out clearly, and in sufficient detail, all the needs and goals that people have and how they are going to support the person. Care plans should be regularly reviewed to see if the care plan is still working and takes into account any changes in peoples’ needs. Although some progress has been made on improving the care plans this requirement has been made over the last three inspection reports. The home has been advised that it must improve the quality of people’s individual care plans to clearly show what it is doing to support them. They have undertaken some work with a few people to improve the care plans but generally the standard required has not been met. In addition, the home supports people with learning disabilities. The Government produced a White Paper called Valuing People that sets out the
The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 7 principals and aims for learning disability services. One of the key areas in the White Paper is to develop, what is called, more ‘person centred’ planning and services. This issue has been raised with the home over several inspections and work is progressing very slowly to introduce a more person centred care planning system. The issue of the manager having sufficient time to carry out the work required to address the outstanding requirements and to undertaken the normal operational roles and responsibilities has been raised in the previous report and has not been satisfactorily dealt with by the registered provider. They have been asked to provide the Commission with plans on how they are going to resolve this problem. Another requirement that the registered provider has been asked to address is to develop a clear policy and procedure for the use and storage of peoples’ cash cards and PIN numbers. This is to ensure that they are used and secured safely. They have still not provided the Commission with these details. Having a staff team with enough people who have the right qualifications, skills and values to support and promote the quality of life of vulnerable people with high levels of need is essential for all care homes. It has been raised in the report that the home does rely heavily on people accessing specialised learning disability services as the bulk of their regular activities. Although the home has shown that it works hard in finding activities and opportunities for people the range of specialist activities that people in the home can use is becoming more limited. The home must look at the levels of support it provides people to access social, leisure and development activities and ensure that it has the staffing levels available to meet peoples’ goals and needs. Other areas of work that needed attention, that have been raised in the last inspection report, include setting out clearly how the home is going to make sure that its staff have completed the national vocational qualification that all staff need to have to show that they have developed the core skills needed to support vulnerable people. Other areas of work not completed include where it was found that there was no evidence that all the staff team had a Criminal Records Bureau certificate that is an essential check in making sure that staff are safe to work with vulnerable people. In addition, the home had been asked to make sure that all the staff team had a clear training and development plan. Although some progress had been made in recording the training staff had undertaken this did not show fully what the staff had achieved, what training they needed and whether the staff had learnt to put in place those new skills. The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 8 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 Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s needs would be identified before being offered a placement at the home. EVIDENCE: There had been no new arrivals to the home since the last visit. The referral process was described by the manager. If the home had a vacancy then they would inform the local authority care management team or place information on a dedicated web site on the internet. If a person was identified then they would visit the person and any relevant people, such as family, and undertake their own pre-admission assessment. The home would also expect a full Community Care Assessment from the purchasing local authority. From this information they would decide whether the home can meet that person’s needs and arrange for a series of visits to the home. Information in the form of the Service User’s Guide would be provided to the relevant people to help them make a decision. The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home encourages and supports people to make relevant choices, decisions and risks about their lives. However, the care planning system does not yet fully reflect peoples’ current and changing needs and goals. EVIDENCE: The new care planning process and format seen at the visit in February 2006 had not yet been fully implemented. Three of the 12 people had new care plans and the manager and acting deputy were working towards completing the remainder. As the older style care plans are still being used for 9 of the people at the home that do not yet reflect people’s holistic needs and support a requirement was made. Evidence was seen of peoples’ Care Management reviews that were undertaken on a yearly basis and looked at the overall care and support of the person at the home. The need for the home to develop a review system of peoples’ needs and support had still not been implemented. The manager is aware of the need for
The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 12 a review system and stated that they will develop this once all the care plans has been developed. It was found that the home’s daily recording was at times very brief and did not accurately reflect the needs and goals identified in a person’s care plan. It is recommended that the daily recording accurately reflects people’s care plan goals and needs. It is also recommended that the staff team become more involved in the care planning process. This is being considered by the manager who aims to introduce this in the near future. People were encouraged and supported to express their views and opinions about the home. People have the opportunity to meet together to discuss issues such as domestic arrangements, meals, social activities and holidays. One of the group takes the minutes of the meetings. Restrictions of choice were only applied as a result of a risk assessment and involvement of the person and other relevant people. Through discussions with the manager and evidence seen at the home it was shown that issues of equality and diversity that have an impact on peoples’ lives were taken seriously and the home had worked with people and other specialist providers to help address the issues that people experience. The home’s risk assessment process includes a general assessment in areas such as medication, mobility and communication. This gives an overall guide to whether further more in-depth assessments were required. There were some examples of these fuller assessments. It was found that where there had been changes in people’s circumstances, such as health a new risk assessment had been undertaken to reflect the new risks and hazards faced by the person. This action met the requirement made in the previous inspection report. The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported and encouraged to participate in a range of specialist and community based social, leisure and educational activities. The home actively encourages and supports people to maintain relationships with their families and friends and the routines of the home are based on people’s individual needs. People are offered a healthy balanced diet that they enjoy. EVIDENCE: The majority of peoples’ daily activities involve attending specialist services for learning disabled people. This includes day services, drop-ins and local college courses. People discuss the social and leisure activities that they are interested in during house meetings. Small groups of people have been supported to visits to the cinema, bowling, eating out and day trips to local attractions. People are encouraged and supported to maintain and develop their independence skills through allocated domestic tasks within the home and through maintaining their own bedrooms. People can access local colleges for
The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 14 courses that develop new skills and education and several people are participating in an access to work course. People are also supported and encouraged to become involved in appropriate work placements. An issue that was recognised by the staff and management as beginning to have an impact on people is that local colleges have stopped delivering leisure classes. Several peoples’ college course was cancelled mid-way through the year. Also, a person recently had their day service allocation reduced from 4 to 3 days per week. These events have a clear actual and potential impact on the activities that people participate in and on the in terms of support levels. This issue is further discussed in the Staffing Section of this report. Several people are able to travel into the community independently to use local shops, facilities and to visit family and friends. Those people that need it are supported to attend the local churches and local amenities such as shops, cafes and libraries. A variety of transport is used including Ring and Ride, public transport, staff cars and taxis. The home discusses with people what holidays they want to take and have supported them to a variety of locations both in the United Kingdom and in Europe. Several people regularly go and stay with their family and families and friends are encouraged to take an active part in people’s lives. Each person has their own daily and weekly routine based on their own needs and the activities that they participate in. The home have developed a written routine guide that shows information about each person’s routine and include details such as what activities they are involved in, when they like to get up/go to bed and how they like to be supported. Information about what people like and don’t like to eat was well known by the staff and this information was used to develop the weekly menus. The main meal included both a hot and cold choice and individual preferences were accommodated where possible. There was a good stock of fresh and frozen foods. The Boundary DS0000021605.V291379.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 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home supports people to maintain their healthcare needs. The home cannot show that it fully meets all peoples’ personal care needs in the most appropriate manner. The medication administration systems and practices do not fully protect people. EVIDENCE: People were encouraged and supported to maintain their personal care skills. Those people who require support is clearly recorded in the person’s care plan. Where required the home has sought the advice and support from specialist services such as occupational therapists to meet people’s changing personal care and mobility needs. The building has had additional rails and aids installed to help people remain as independent as possible. Due to a change in a person’s health and mobility they moved from a first to ground floor bedroom. However, there are no bathroom facilities on the ground floor and the person cannot get up the stairs safely. Their personal care needs are being met through full body washes and bed baths. The person’s situation has been discussed with the District Nurses who support this person. This situation has gone on for over two months and although the home have carried out new risk assessments and support plans the situation cannot continue as it
The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 16 is. The home must put forward an action plan of how they are going to meet the named person’s long-term personal care and mobility needs. The home supported people to access general health services on a regular basis to maintain their health and wellbeing. Support was also provided via the local G.P and specialist healthcare professionals such as psychiatry. The medication administration system was checked and found that all medication administered had been signed for on the MAR sheets. A list of staff signatures had been gained. Deliveries of the monitored dosage systems was made on arrival and recorded on the MAR sheets. Staff who administer medication have undertaken additional medication training. It was found that at times the home transfer medication into a separate dosette box for people to take with them. It was explained to the manager that this was secondary dispensing and must stop immediately as it is not safe. The Boundary DS0000021605.V291379.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 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People were aware that they could raise complaints and concerns about the home. The systems and practices to protect people from all forms of abuse had not been implemented. EVIDENCE: The home’s complaint policy and procedure were in place. The home had implemented a complaint log that contained the appropriate headings for recording and dealing with complaints. There had been no formal complaints since the last inspection. People were aware that they could raise their concerns with the home or speak to other people they trusted. It is recommended that the home maintain a record of the concerns and worries that people raise that require the home to take some action to resolve the issue. The home had adopted the Manchester multi-agency policy on the Protection of Vulnerable Adults from Abuse. A copy of the Department of Health guidance document, ‘No Secrets’ was also held at the home. Care staff had received training in the Protection of Vulnerable Adults (POVA). The last two inspection reports have required the registered provider to develop a policy and procedure on the use and storage of peoples’ cash cards and PIN numbers and provide the CSCI with a copy within the timescale stated. This has still not been actioned and the requirement was reiterated again. The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a homely, clean and safe environment. EVIDENCE: The premises were generally clean and tidy and areas were well maintained. The décor and furnishings were homely in nature. Since the last inspection the lounge areas and kitchen had been redecoration. Any maintenance issues were recorded and past onto the registered provider to resolve. The requirement to make good repairs to the kitchen door, kitchen window and fire doors had been actioned. The laundry facilities were sited in an outbuilding and were sufficient to meet people’s needs. Staff wore plastic aprons and gloves for cleaning and when personal care was required. Cleaning materials were kept locked in storage. The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 19 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home had started to provide the formal support staff require. The home does not fully have the systems, procedures and practices in place to ensure that staff have the required vocational and client based training they require to meet people’s needs. The home does not have the recruitment systems in place to ensure that staff are safe to work with vulnerable people. EVIDENCE: At the current time none of the support workers have gained a vocational qualification. Two staff were undertaking the course but the NVQ provider had dropped out. The manager stated that they were in the process of finding a new NVQ provider for the staff team. The staff team is made up of the manager, a deputy and acting deputy manager and six other support staff. The manager and acting deputy work fulltime and the rest work a range of part-time hours. The rota for the week 3rd to 9th of April 2006 showed that the team provided 216 hours of support. Of these 56 hours were from the manager and 56 from the acting deputy manager. The issue of the use of the manager’s time will be raised in standard 37. The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 20 It was seen that during two days of the mid-week a total of an extra 8 hours had been provided to support people to access social and leisure activities. One of the reasons that this was required was due to the reduction of specialist college and day services made available to people and so more people being at home during the day. This situation is likely to continue and could even increase. The issue of the home providing sufficient support was raised in the last inspection report. The registered provider must provide sufficient staff, throughout the whole week, to support and meet all of people’s needs (including social and leisure). The registered provider must provide the CSCI with an action plan outlining how they plan to provide this support. The previous inspection report highlighted that staff files did not contain the required documentation. The home could not provide details that Criminal Record Bureau (CRB) disclosure checks and POVA checks had been made on all the staff team. The requirement was reiterated that the registered provider must ensure that staff files contain all the documentation required as set out in Schedule 2 of the Care Homes Regulations 2001 and that up-to-date CRB/POVA checks have been made on all the staff team. Evidence that these documents have been sought must be provided to the CSCI within the timescale set. In September 2006 the Skills for Care Induction modules becomes a compulsory induction programme for all social care staff. The home’s induction programme must be reviewed and updated, were required, to meet the requirements of the Skills for Care Induction. Evidence of the new induction programme must be submitted to the CSCI within the timescale set. The home provides an induction and core-training programme based on the Learning Disability Award Framework. This core programme consists of Moving and Handling, First Aid, Food Hygiene and Health and Safety. Each member of staff had a training record that included the core and any other additional training that they had participated in. The record was not accurately dated. It was not clear from the record whether the training events stated were ones that the staff member was going to attend or not. Also the record did not include the induction programme. The role and substance of a staff training and development plan was discussed with the manager. The previous requirement relating to the development of a training plan was reiterated. Whilst staff may have undertaken the home’s induction and core training programme the home has no system to evidence that staff are competent in the core skills required to support people. It is recommended that the home introduces a system of evidencing staff competence in the implementation of the core skills developed through the home’s training programme.
The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 21 The manager stated that they were undertaking formal supervision with staff and were using a set supervision agenda. The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a system of quality assurance that seeks people’s views. The home has the systems and practices in place to protect peoples’ health and safety. Due the current management arrangements people and staff do not benefit from a well run home. EVIDENCE: The last inspection report highlighted that the majority of the manager’s hours were spent providing people with support. The registered provider had allocated one day a week for the manager to spend covering her managerial responsibilities and undertaking the work required to address the requirements made from previous inspections. This situation remained the same and although the manager has made some progress in actioning the requirements, as this report shows, there are several areas of work that require attention and the manager does not appear to have the time to undertake the actions required. A deputy manager is being trained
The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 23 to take on some of the manager’s responsibilities but she has not yet been able to delegate many of these tasks. The manager must be given the time and resources to carry out her managerial role and responsibilities and action the requirements for the home to meet the National Minimum Standards. The registered provider must provide the CSCI with written evidence that this has been actioned. The home does have a quality assurance programme that has recently used a range of questionnaires completed by people at the home, relatives and friends and other professionals who come into contact with the home. The questionnaires asked general questions about issues of quality about the service. The outcome of such an exercise should be the development of a report and action plan relating to the information gathered. It is recommended that the registered manager provide the CSCI with the report/action plan generated through the quality assurance process. The home was maintaining an accurate fire log with the required checks and fire drills. Equipment was being serviced on a yearly basis. A new fire alarm and smoke detectors had been installed recently. The home would check the temperatures of hot water when supporting people to take baths and maintains a regular, ongoing record of all the hot water sources in the house. The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME 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 2 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 3 X X 3 X The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15 Requirement Timescale for action 30/06/06 2. YA6 15 People’s care plans must clearly and accurately reflect their holistic needs, goals and the support required to meet them. Peoples care plans, goals and 30/06/06 the support they receive must be reviewed and evidenced at least every six months. (Previous timescale of 01/11/05 and 01/04/06 was not met) The home must put forward an action plan of how they are going to meet the long-term personal care and mobility needs of the person discussed during the visit. The practice of secondary dispensing of medication must stop and alternative means of dispensing established. The registered provider must develop a policy and procedure for the use and security of peoples debit cards and PIN numbers and provide the CSCI with a copy within the timescale stated. (Previous timescale of 1/10/05 3 YA18 12 01/06/06 4 YA20 13 01/05/06 5. YA23 13 30/05/06 The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 26 and 01/04/06 was not met). 6 YA33 18 The registered provider must provide sufficient staff, throughout the whole week, to support and meet all of people’s needs (including social and leisure). They must provide the CSCI with an action plan outlining how they plan to provide this support. The registered provider must ensure that staff files contain all the documentation required as set out in Schedule 2 of the Care Homes Regulations 2001 and that up-to-date CRB/POVA checks have been made on all the staff team. Evidence that these documents have been sought must be provided to the CSCI within the timescale set. (Previous timescale of 01/04/06 was not met) 8. YA35 19 Each member of the staff team must have a training plan and log that sets out the training they have achieved and are required to undertake. Evidence of the staff training plans must be submitted to the CSCI within the timescale set. (Previous timescale of 01/04/06 was not met). The home’s induction programme must be reviewed and updated, were required. Evidence of the new induction programme must be submitted to the CSCI within the timescale set. (Previous timescale of 01/03/06 was not met) 30/06/06 30/05/06 7. YA34 17 30/05/06 9. YA35 19 30/06/06 The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 27 10. YA37 19 The manager must be given the time and resources to carry out her managerial role and responsibilities and action the requirements for the home to meet the National Minimum Standards. (Previous timescale of 01/03/06 was not met) 30/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA6 YA6 YA22 Good Practice Recommendations It is recommended that the daily recording accurately reflects people’s care plan goals and needs. It is recommended that the staff team become more involved in the care planning process. It is recommended that the home maintain a record of the concerns and worries that people raise that require the home to take some action to resolve the issue.
DS0000021605.V291379.R01.S.doc Version 5.1 Page 28 The Boundary 4 YA32 5. YA35 5 YA39 It is recommended that the home must provide the CSCI with an action plan setting out how they are going to meet the targets for achieving 50 of staff obtaining NVQ level 2 within the timeframe set. It is recommended that the home introduce a system of evidencing staff competence in the implementation of the core skills developed through the home’s training programme. It is recommended that the registered manager provide the CSCI with the report/action plan generated through the quality assurance process. The Boundary DS0000021605.V291379.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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