Inspection on 13/04/07 for The Mount

This inspection was carried out on 13th 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Mount 23/04/08

The Mount 08/12/05

The Mount 30/06/05

The Mount 05/10/04

The Mount 21/04/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 The Mount 29 Palmer Lane Barrow On Humber North Lincolnshire DN19 7BS Lead Inspector Janet Lamb Unannounced Inspection 13th April 2007 13:00 DS0000002815.V336183.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 DS0000002815.V336183.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. DS0000002815.V336183.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mount Address 29 Palmer Lane Barrow On Humber North Lincolnshire DN19 7BS 01469 532897 F/P 01469 532897 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) info@prime-life.co.ukwww.prime-life.co.uk Prime Life Limited Position Vacant Acting Manager is Leanne Sanders Care Home 17 Category(ies) of Learning disability (17) registration, with number of places DS0000002815.V336183.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home must now adhere to the Residential Staffing Forum guidelines in respect of staffing levels. 8th December 2005 Date of last inspection Brief Description of the Service: The Mount in Barrow on Humber, owned by Prime Life Ltd, provides personal care for 17 adults with learning disability, in single rooms (except for one double), on two storeys. The main house, which sleeps 13, and two bungalows, which sleep one and three service users, are all set in their own grounds, and although the main house is not suitable for people with physical disabilities, one of the bungalows is adapted for wheelchair use. The home’s charges range from £312.00 to £918.50 per week, for which care and accommodation are provided. Service users are required to purchase their own clothing and toiletries, to pay for meals out if they chose to take them, and to pay for use of the home’s transport by making an agreed monthly contribution. Local shops and amenities are close by in the village and the home has its own transport. There are large gardens for residents use, which are used extensively in the summer months. DS0000002815.V336183.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process began in January 2007 with the receipt of the Commission’s pre-inspection questionnaire. Relative, Health & Social Care Professional, and Care Manager comment cards were issued in early February in order to get the views of people that have an interest in the service of care provided. At the same time service users and staff were sent questionnaires to obtain their views of the service. Information was also taken from the notifications that have been sent to the home since the last inspection. All of this was collated to suggest what it must be like for service users living in the home. Then on the 13th April 2007 Janet Lamb carried out a site visit to test whether or not those suggestions were true. Three service users, two staff, and the Manager were interviewed, staff and service users were observed during some of the visit, permission was obtained to look at some of the documents, records and files belonging to service users, and the communal parts of the house was viewed as part of the inspection process, as were two bedrooms, again with permission. Two relatives were contacted on the telephone to discuss their opinion of the care provided. What the service does well: Service users are assessed before they receive a service of care and support in the home, and they are provided with some information about the home and staff in order to decide whether or not their needs can be met there. Service users have their needs and changing needs recorded in a plan of care, which takes into consideration their individual differences. They are encouraged to make their own decisions about daily life, as much as possible, which may involve taking risks in order to achieve independence. However, these risks are reduced where possible. Service users take part in appropriate community based activities and pastimes within the home or in the community, they enjoy relationships of their choosing with good advice coming from staff, and have their rights and responsibilities as citizens upheld wherever possible. They said they enjoy shopping, walking, going on outings, going to pubs and restaurants, listening to music, doing activities in the garden, helping with household chores and preparing meals. DS0000002815.V336183.R01.S.doc Version 5.2 Page 6 Service users also enjoy a variety of meals, many of their choosing, and assist in the provision of and preparation of food wherever possible. Service users say they receive the help and support with personal care and with physical and emotional health needs in a way that suits them. Service users have their views listened to and feel confident they can make representations or concerns and complaints known to the staff or the Manager. What has improved since the last inspection? What they could do better: The service could up date the written/pictorial information it provides to service users to help them decide whether or not they want to visit and try out the home, and it could make sure all service users actually receive the information. It could encourage service users to exercise their ability to make choices and decisions more often. The service could make sure controlled drugs are stored in a double locked facility, that they are recorded and signed by two staff when given in a controlled drugs register. More of the staff could be trained in the safe administration of medication and those already trained could be given refresher training on a yearly basis. It could make sure all staff receive up to date training in safeguarding adults issues and procedures/policies/protocols, stated by the local authority. It could also make sure more staff undertake and achieve the NVQ level 2 and 3 qualification in Care, or equivalent. DS0000002815.V336183.R01.S.doc Version 5.2 Page 7 The service could make sure there are more staff employed in the home and that more care hours per week are allocated to service users that are increasingly staying home more often due to loss of day service places. The service could develop its quality assurance systems to check that the needs of service users are being met to aid their personal development in line with the details of their care plan programmes, not just to focus on areas of managerial responsibility that indicate whether or not National Minimum Standards are being met. 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. DS0000002815.V336183.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 DS0000002815.V336183.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 and 5. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. They have their needs well assessed so they are confident they will be met. They do not receive sufficient up-to-date written/pictorial information though to help them decide if the home is the right place for them. Statements of terms and conditions of residency are poorly produced, as they do not contain all of the information required. EVIDENCE: Interviews with service users, staff and management reveals that some service users have lived in the home for up to twenty years, while others have only lived there for the last twelve months or so. One service user new to the home remembered having an officer of the North Lincolnshire Council take down information prior to moving to The Mount and was given verbal details of the place, as well as being accompanied to look around. He was very clear that he had not been given any written documents though; no statement of purpose and no service user guide. He said, “__ helped me to look for this place, but I didn’t get any information about it.” DS0000002815.V336183.R01.S.doc Version 5.2 Page 10 These documents were discussed with the Manager, but only the service user guide could be produced for viewing. It contained details in written English and picture format. The two pages available of the statement of purpose were noticeably out of date and therefore a requirement is being made to produce an up-to-date one, which contains all details of the new staffing structure, their qualifications and the changes made to the fabric and structure of the home, which are detailed below in the environment section. Permission was obtained from three service users to look at their case files and although all three contained a council ‘Community Care’ care plan, they did not contain a council Community Care Assessment form. They did contain Prime Life care plans, which showed an assessment element to each section and which had been reviewed monthly, and the council care plans had been renewed annually, two within the last twelve months and the third not held at all yet because the service user has only been in the home eight months. Service users’ statements of terms and conditions of residency do not contain all of the information required in standard 5.2 and the document therefore needs reviewing, and adding to the service user guide, once complete. Case files are more organised and consistent in their content and format, and contain only relevant information, old information having been removed and archived. DS0000002815.V336183.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. They have good care plans in place that show how their needs are met; they enjoy different levels of decision-making, and take appropriate risks according to risk management systems in place. Service users’ individual needs are well met, but they could experience more autonomy in decision-making so that they can lead more independent lives. EVIDENCE: There are three groups amongst the service users living at The Mount, one that lives fairly independently in the bungalows and enjoys deciding many of the daily issues for themselves and engages in household chores as well as such as listening to music, completing jigsaws etc. These people also question why things happen in their lives and sometimes go places or do things that put them outside of the risk assessments in place to help protect DS0000002815.V336183.R01.S.doc Version 5.2 Page 12 them. They are more able to understand the risk they take and generally require greater advice and support to live their lives. One said, “Staff support me when I need it, but most of the time I do things myself. The Manager has stopped me doing some things though, but at least she doesn’t tell us what to do.” The second group of service users are those living in the main house that also make many decisions for themselves, about their daily activities etc. but may often only do so with the advice and support of staff. Their lives are relatively without event, but they did indicate they go out on outings, which is what they mainly look forward to. One said, “I like going out.” On speaking to these service users they are quite satisfied with the way life is, and when asked if they thought they could challenge things said they didn’t want to ‘rock the boat.’ One said, “I asked for a certain cereal the other day and got the wrong one, but I didn’t complain about it. It didn’t matter.” They seem to be a group of people that generally accept life the way it is and will be and that staff that support them will influence some of their decisions. This was the impression they gave when discussing their daily routines and their opportunities to engage in pastimes. The Commission asks the service to show how it can develop service users’ competence to exercise greater autonomy. The third group of service users are those also living in the main house that are unable to communicate with the spoken word, but manage to make gestures and use body language to express their like or dislike of what happens. They were observed to be relaxed, comfortable and interested in other people and events. Staff spoken to clearly express the view that some of these people are unable to make informed decisions of their own. They accept that basic decisions to eat, drink go to sleep etc. are made by service users, but decisions such as choosing to engage in an activity or to go on an outing are not made entirely by them and in the full understanding of what is happening. These service users are either happy going with staff and each other out of the house, or they are not. The true reasons for leaving the house are not known to them, until they actually arrive at their destination. Staff also express the view that these service users are unable to make decisions about things such as the clothes they wear. All service users have a care plan at The Mount, which describes how their assessed needs are met and they, or if they are unable their relative, signs them. Three were seen as part of the case tracking. They include thirteen areas of living, ability and safety and show how service users are supported to achieve and maintain for example good mobility, personal hygiene and a level of activity that fulfils them. Care plans are reviewed each month on an evaluation sheet and each year as part of the council’s requirements. The DS0000002815.V336183.R01.S.doc Version 5.2 Page 13 council review is recorded on a North Lincolnshire Council Learning Disability review document, which asks the service user and the staff what they should like to discuss in the review meeting, shows who is invited, who actually attends and then has a section at the back to show what action will be taken and by whom as a result of the meeting. This acts as evidence that the meeting has taken place and shows what the outcomes are. There are also risk assessment documents held in service users files that cover a range of areas of risk; going out, crossing the road, taking a bath, making a drink/snack in the kitchen, experiencing seizures etc. These assist service users in making decisions about actions or events that may be risky. DS0000002815.V336183.R01.S.doc Version 5.2 Page 14 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, 15 16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. Some changes have been made, which means some service users are less independent in some areas but others are enjoying a more satisfying lifestyle. EVIDENCE: Discussion with service users and staff reveals service users generally fall into three groups, as mentioned in “Individual Needs and Choices”, in respect of being able to take up opportunities to develop and maintain social, emotional, communication and independent living skills, to take up jobs or college work, to join in with the community, and to choose leisure activities and healthy foods. DS0000002815.V336183.R01.S.doc Version 5.2 Page 15 Four service users currently living in the bungalows on semi-independent programmes also have varying needs, which some relatives feel are not particularly well matched. Service users themselves stated they would like to be involved in more outside activities and have jobs or occupations, which take them out each day. One service user said, “I used to have a job in Barrow, but things went wrong, so I can’t go there now.” Relatives spoken to thought service users could be encouraged more to develop independent living skills. Another service user was observed heating up his mid day meal. A third service user in the bungalows has a job assisting at a day centre and enjoys the tasks she performs. Service users in the main house, two groups, are of the same inclination when it comes to working and keeping busy. One said, “I clean out my bedroom each week, but I’d really like to do some work in the office. There isn’t enough for me to do though.” Another said, “I always help in the kitchen washing pots, some are not capable of doing it you know. I clean my bedroom as well.” Both said they very much enjoy going out on the bus for outings. They were looking forward to going to Whitby on the next planned outing. Those that are unable to verbalise their feelings and views rely on staff to suggest, set up and assist in doing activities and going out etc. and generally these take the form of listening to music, engaging in tactile pastimes and going out for rides on the home’s transport. These service users may take a short trip out as part of transporting someone else to a chosen/required destination. All service users take part in some activities in the village, either visiting the local shop and pub or going to church. Some walk into Barton, others take the home’s transport. A monthly charge is made to all service users using the home’s transport and they sign an agreement to that effect. All service users have contact with family and friends, but relatives indicate information that comes to them is not sufficient or frequent enough. Relatives do state that whenever they visit the home staff are friendly, welcoming and helpful. Service users spoken to state they generally have freedom of movement around the house, can decide things for themselves, come and go as they please and are quite happy with the way things are. Routines are relaxed and individual to each service user. Menus within the main house are compiled by the staff, with some input from service users stating their likes and dislikes. Although one service user expressed some disappointment at being given the wrong breakfast, he and the other service users state they are satisfied with meals and choices. DS0000002815.V336183.R01.S.doc Version 5.2 Page 16 The service users in the bungalows have individual weekly budgets, which they have agreed to combine. They are responsible for determining their weekly menus and shopping list, and for doing the shopping at weekends, as part of their independence training. Service users and relatives indicate they are not receiving the right level of supervision to make sure menus and shopped items correspond. Therefore service users often run out of essential items and do not get the meals they have planned. Sometimes they have to eat in the main house to ensure they take a meal. Information obtained from the Manager reveals service users are taken shopping each Friday and are guided by staff to purchase items to suit planned menus. Service users had gone through a period of purchasing individual food supplies, but were consuming their own foods and each others at night when staff were not available to guide them, and so separate cupboards had to be set up with locks to ensure this stopped. Each service user had a key to their own store. Since then service users have agreed to share again and now only have separate locked cupboards for snacks. Service users still consume foods at night when unsupervised and still run out of items. Relatives spoken to express concerns that service users are not being monitored properly in respect of budgeting and preparing meals, or supervised at the right times and it may be that the problems are occurring because of insufficient staffing levels identified in the “Staffing” section. Service users are not having their individual development reviewed regularly enough and risk assessments put in place to identify the need to make changes to their support. Generally food consumed is according to service users choice and preference and they are satisfied with the outcomes. DS0000002815.V336183.R01.S.doc Version 5.2 Page 17 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 and 20. People who use the service experience adequate quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. Service users receive good assistance and support to maintain their personal and health care, so they are confident their needs will be met. They do not experience the opportunity to selfmedicate, so their levels of choice and independence are not good, and medication systems are only adequate in respect of storage and recording of controlled drugs, so service users could be at risk of mistakes being made. EVIDENCE: Discussion with service users, staff and the Manager reveals service users are encouraged to take responsibility for their personal healthcare and they are assisted with personal support in a flexible, dignified way. They are not encouraged to retain and administer their own medication. Service users have varying levels of need in respect of personal and health care support, but all of those that are assisted with personal care receive DS0000002815.V336183.R01.S.doc Version 5.2 Page 18 assistance in privacy, and according to their preferences and wishes. Two service users said, “I only need help with washing my hair and cleaning my back.” Another said, “I need help with shaving sometimes.” Others, it was reported by staff, require full assistance with personal hygiene and dressing etc. Care plans and diary notes seen confirmed the levels of support and assistance required and received. Service users in the bungalows are self-caring and require only support, guidance and prompting with personal care and housekeeping. Their care plans and diary notes seen also confirm the support and guidance they receive. Changes have been experienced in the handling and administering of medication. Staff now administer medication to all service users, even though some had been self-medicating for a while. Reasons for this change were discussed with the Manager, but it was decided that some level of independence should be offered to service users to self-medicate again, ensuring a better system of monitoring is in place. Medication administration systems are adequate, but could be better. Boots monitored dosage system is used, drugs are receipted into the home, stored appropriately in locked facilities, except for the controlled medicines, and are administered according to instructions and only by staff that have been trained to do so (eight in total, although two of these were trained almost three years ago, and three were trained two yeas ago. Only three have had recent training). The Manager explained a pharmacy audit had not been undertaken for some time and had been arranged for May 2007. Medication administration record sheets are in place, used appropriately and show medicines are signed for after administering them. Controlled drugs are not being recorded in a separate register but on the general record sheets. There is a need to obtain a controlled drug register and to ensure two staff sign upon administration. Service users files seen, showed they have details in relation to their health needs and information in the care plans to meet them, are being assisted to attend health checks, appointments and outpatient appointments as necessary, but that they are not being given the opportunity to selfmedicate. DS0000002815.V336183.R01.S.doc Version 5.2 Page 19 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 and 23. People who use the service experience adequate quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. Although service users are confident their concerns and complaints are listened to and acted on, and they will be safeguarded against harm or injury, the Commission is not satisfied they are safeguarded, so service users are not properly protected. EVIDENCE: Discussion with service users, staff and the Manager, and viewing of documents and procedures reveals service users and relatives have opportunities to make concerns and complaints known, have made complaints and have had these satisfactorily dealt with, although information from relatives implies they have taken complaints to the company before and have not been satisfied, therefore they now take issues directly to North Lincolnshire Council. The home has a complaint procedure on show, maintains a record of complaints received, of which four were recorded since the last inspection, and deals with issues appropriately. These complaints were all unsubstantiated. Service users say they would talk to the staff or the Manager if they had any concerns or were unhappy about anything, and that they would do the same if they felt they or any other service user was being hurt in any way. DS0000002815.V336183.R01.S.doc Version 5.2 Page 20 Although the view of generally maintaining the safety of service users is considered to be satisfactory, the overall view of the safeguarding adults systems is that it is only adequate. Service users are relaxed, comfortable and contented when talking about living at The Mount and also sat they know who to pass concerns onto if they have any. They consider the staff to be helpful, friendly and supportive. However, staff have not had the appropriate safeguarding adults training and they could not satisfactorily relate the procedures for handling issues of safety and vulnerability. All staff must undertake appropriate safeguarding adults training and be able to demonstrate their understanding of the protocols, procedures and policies of both the North Lincolnshire Council and of Prime Life. Information provided by Prime Life showed only two staff have done the company training, although the Manager believes four have read the booklets available. There was insufficient evidence available to show the staff team has the satisfactory training and experience to safeguard the protection of service users. DS0000002815.V336183.R01.S.doc Version 5.2 Page 21 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 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. Service users enjoy a clean, safe and homely environment, in a home that is suited to it stated purpose. EVIDENCE: Discussion with service users, staff and the Manager and a brief tour of the building in respect of communal areas, reveals there has been some recent redecorating of the dining room and one of the lounges, and that service users find the house clean and comfortable. The general atmosphere has improved in terms of comfort and cleanliness and the lounges and dining are light and airy. There has been a complete ‘u’ turn done with the Jacuzzi room, which was installed approximately two tears ago and now reported to be underused. DS0000002815.V336183.R01.S.doc Version 5.2 Page 22 This area has now been converted into two single bedrooms with en-suite toilets and showers, and an extra toilet and shower facility for general use. The rooms were finished on the day of the site visit and now only require furnishing. It is expected an application to register the rooms shall be made to the CSCI imminently. The rooms must not be used, nor the number of service users increased, until they have been registered. Two service users bedrooms were also seen with their permission and they too were clean, comfortable and very personalised. The house suits its stated purpose and provides a very homely atmosphere. DS0000002815.V336183.R01.S.doc Version 5.2 Page 23 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, 33, 34 and 35. People who use the service experience poor quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. Service users do not benefit from well-trained staff in sufficient numbers to meet their needs, though staff are adequately recruited. EVIDENCE: Discussion with the staff and the Manager, viewing of staffing rosters and allocated hours, and calculating the recommended Residential Staffing Forum figures reveals standards 32, 33 and 35 are not met, but that standard 34 is. There are insufficient staff in the home with the recommended qualifications. Insufficient hours are being allocated each week to meet the needs of service users, and although Prime Life has appropriate systems in place to provide adequate mandatory training in line with the Skills for Care and the Learning Disability Award Framework (LDAF), these have not been used effectively. DS0000002815.V336183.R01.S.doc Version 5.2 Page 24 Information provided shows that of the fourteen staff working in the home only two have achieved NVQ level 2 and only one more is undertaking the award. All staff have been signed up to do the LDAF induction and foundation and some have been registered to do NVQ staring June 2007, but this is a long time after their recruitment. Prime Life should ensure all new staff are quickly put onto these courses after being recruited. Standards 32 and 35 are not met. There are insufficient staffing hours allocated each week to meet the needs of service users. The home is providing 483 hours (378 plus 105 extra for 11 care) per week, but the recommended staffing forum figures state there should be 594.70. This equates to a shortfall of 111.70 per week. Figures do not include the Manager’s hours and although it is acknowledged that some of her hours may be allocated to caring, no more than half should be and only in times of emergency and shortage. The forum also recommends that there should be 19 full time equivalent staff working in the home. There are 14 plus the Manager. Standard 33 is not met. Recruitment and selection of staff is according to the company’s policy and procedure and records held in files showed all required checks are made before a new staff begins working in the home. Discussion with staff confirmed the recruitment procedures. Standard 34 is met. DS0000002815.V336183.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 and 42. People who use the service experience adequate quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to this service. Service users benefit from having a Manager that is competent and is maintaining consistency within the service, but is not qualified or registered yet. They have use of a quality assurance system, but this is not effective in demonstrating their individual development in relation to their care plans. They experience adequate protection from harm under the home’s health and safety measures in place and the practices carried out to maintain service users’ and staff health, safety and welfare. EVIDENCE: Discussion with the Manager reveals she has NVQ level 2 In Care, and has enrolled for level 4 as well as the Registered Manager’s Award, but neither DS0000002815.V336183.R01.S.doc Version 5.2 Page 26 course has begun yet. She has several years experience in a senior role working with Prime Life. At the moment she does not meet the criteria for the role of Registered Manager. Standard 37 is not met. There is a quality assurance system in operation for assessing the home’s quality of care, which involves surveying service users, relatives and staff and checking of documentation and care practices etc. in the home. In November 2006 Prime Life provided the Commission with a copy of their internal ‘quality assurance review’ report, which showed the outcomes of their own survey and quality assurance checks. Main areas identified for improvement were the updating of the statement of purpose and service user guide, the need to have a pharmacy audit on medication handling and administration, to offer advocacy services to service users, to increase the number of staff with NVQ qualifications, and for the Manager to enrol on NVQ level 4 and submit an application to register with the Commission. The quality assurance system needs to be developed to look at individual development for each service user as a result of the service provided, and not just to focus on areas of managerial responsibility that indicate whether or not National Minimum Standards are being met. Standard 39 is not met. Information was received from Prime Life in the Commission’s pre-inspection questionnaire that stated fire safety, gas and electric engineer checks, and such as Legionella checks are all up to date. Areas of health and safety sampled during the site visit were fire safety, Legionella testing, and risk management. Records show fire drills are carried out each month, that extinguishers are checked annually (last maintained January 2007), and that there is a fire risk assessment in place, which needs reviewing (last done November 2005), but that weekly checks on the fire safety systems have lapsed and need resuming. The home maintains monthly checks on the hot water temperatures and these are recorded, and although a Legionella test is indicated as been done in December 2006 the home does not have documentary evidence to show this. Other checks made included verifying the last portable appliance test, and viewing certificates for gas and electrical safety checks. There are risk assessment documents in place to cover areas of the home such as the kitchen, fire safety, laundry use, and use of cleaning products etc. These are satisfactory. Standard 42 is adequately met. DS0000002815.V336183.R01.S.doc Version 5.2 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 2 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 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X X 3 X DS0000002815.V336183.R01.S.doc Version 5.2 Page 28 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 YA5 Regulation 5 Requirement The Registered Provider must develop a contract that meets the requirements of standard 5 and regulation 5. (This is a continuing requirement. Old timescale of 28/02/06 has not been met.) The Registered Provider must encourage service users to selfmedicate, within a risk assessment framework and if necessary providing a high level of monitoring, so that service users can become more independent. The Registered Provider must enable more staff to undertake medication administration training, so that service users receiving help with their medicines have more opportunities to be assisted, especially if staff take leave or sickness absence. Those staff already trained need to receive refresher training. The Registered Provider must store all controlled drugs appropriately, so that the home complies with the Medicines Act DS0000002815.V336183.R01.S.doc Timescale for action 30/06/07 2 YA20 12 and 13 30/06/07 3 YA20 18 31/07/07 4 YA20 12, 13 and 23 30/06/07 Version 5.2 Page 29 5 YA23 13(6) 6 YA33 18 1968, the Misuse of Drugs Act 1971 and the guidelines of the Royal Pharmaceutical Society of GB, and so that service users can be confident their medication administration needs will be met in a safe and robust way. The Registered Provider must 31/07/07 make sure all staff undertake safeguarding adults training in line with the local authority’s and Prime Life’s policies, procedures and protocols, so that service users are protected from abuse or harm. The Registered Provider must 31/05/07 provide staffing in sufficient numbers as are appropriate for the health and welfare of service users, and it is expected that the Residential Staffing Forum recommendations be implemented, so that service users’ assessed needs are met. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA2 YA7 Good Practice Recommendations The Manager should try to obtain a copy of each service users’ Community Care Assessment document and maintain them on files. The Manager should enable the staff team to encourage service users to be more autonomous in making decisions about their daily lives, so that service users can become more independent. The Manager should acquire and use a controlled drugs register in which two staff signatures must be obtained upon administration of such medicines, so that service users can be confident their medication administration needs will be met in a safe and robust way. The Manager should make sure there are at least 50 of DS0000002815.V336183.R01.S.doc Version 5.2 Page 30 3 YA20 4 YA32 5 YA37 6 YA37 7 YA39 care staff with the required qualification to NVQ level 2 or 3 standard or equivalent, so that service users needs are met by competent, skilled and qualified staff. The Registered Provider must make an application for the Manager to become the Registered Manager, so that service users benefit from the competent and consistent running of the home. The Registered Provider must make sure the Manager begins the NVQ level 4 Registered Manager’s Award within three months of approval as Registered Manager if she is considered ‘fit,’ so that service users benefit from a qualified Manager running the home. The Manager should make sure the home’s quality assurance systems check that the needs of service users are being met to aid their personal development in line with the details of their care plan programmes, so that service users are confident the QA systems inform the business of any current and future requirements to meet their needs. DS0000002815.V336183.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000002815.V336183.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. 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