Inspection on 22/02/06 for The Old Galleries

This inspection was carried out on 22nd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Old Galleries 13/03/09

The Old Galleries 14/03/07

The Old Galleries 18/09/05

The Old Galleries 15/03/05

The Old Galleries 13/08/04

The Old Galleries 15/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 The Old Galleries High Street Bideford Devon EX39 3AA Lead Inspector Susan Taylor Unannounced Inspection 10:10 22 February 2006 nd The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 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 Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 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 Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Old Galleries Address High Street Bideford Devon EX39 3AA 01237 478466 01237 425842 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 Barbara M Haywood Care Home 8 Category(ies) of Learning disability (8) registration, with number of places The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. This variation allows three named persons, in the category of MD Mental Disorder to remain in the home The maximum number of placements, including that of the named persons, will remain at 8 On the termination of the placement of the named persons, the registered person will notify the Commission in writing and the particulars and conditions of this registration will revert to the category LD Learning Disability only 18th September 2005 Date of last inspection Brief Description of the Service: The Old Galleries has provided 24-hour care for 8 adults under 65 years of age with learning disabilities. The emphasis of the home is to enable residents to lead fulfilling lives through the development of social and daily living skills. The home is a listed building, situated in the main High Street of Bideford, and has been totally refurbished. The accommodation comprises of single accommodation, five of which have ensuite facilities. To the rear of the property is an enclosed garden, with outbuildings containing a laundry room. There are no parking facilities at the home, but it is in easy walking distance of a number of street parking bays and public car parks. The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took four and half-hours over one day. The purpose was to follow up on requirements made at the last inspection and to focus on key standards covering assessment, individual needs, personal and health care, complaints and protection, staffing and management issues. The inspectors looked at records, policies and procedures and interviewed the manager and other staff. Three residents gave their views about the home to the inspectors. What the service does well: What has improved since the last inspection? The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 Page 6 The home has received recognition for the work done with learning disabled people, and is now registered with the Autistic Accreditation Society. Staff are soon to have training that will help them care for people with autism. What they could do better: 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 Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 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 The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 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 The admissions process is well managed ensuring that resident’s needs are assessed prior to moving into the home. EVIDENCE: Three residents’ assessments were inspected. The home’s assessment process and documentation is good, ensuring that comprehensive information is known about people moving into the home. In addition to this, the home had obtained a copy of the care management assessment for all of the residents, which included a care plan and these were seen on files. The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 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 Old Galleries staff are responsive to the changing needs of their residents, which are reflected in regularly reviewed care plans. Money is well managed at the home. Residents are enabled to lead their lives in the way they choose to. The home has a system in place to assess risks, which support residents to be independent. EVIDENCE: Three care files were inspected. All had care plans that had been regularly reviewed. Plans of care gave sufficient detail about the needs each resident had, and covered mental, physical, medication, social, personal care, and activities of daily living. A group of three residents told the inspector that their care plans are discussed with them individually, and that they are asked what they would like to achieve to maximise their independence. The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 Page 10 Residents told the inspector that they were enabled to make decisions about their lives. Examples given included having regular meetings to discuss life in the home. With regard to the management of personal money, the inspector was told that every person had an individual record that was signed by the resident as they received whatever amount of money they wished to have. Three records were inspected and crosschecked against balances kept for safekeeping. Balances corresponded with written records. The manager told the inspector that all of the residents had their own savings accounts, into which money was paid on a regular basis. Risk assessments were seen on three files that had been regularly reviewed. These clearly identified risks and set out strategies for minimising risks, whilst at the same time supporting residents to be independent. The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 Page 11 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): None EVIDENCE: The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 Page 12 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 Staff at Old Galleries make good use of health and social care resources available to them in the community to ensure that residents receive the best care available. Residents are treated with dignity and respect. Medication appears to be safely managed in the home, although there are some deficits in the recording method. EVIDENCE: The inspector observed that privacy and dignity is well maintained in the home. Three residents told the inspector that they had keys for their bedrooms. Toilets and bathrooms had locks fitted. The group of residents verified that they had been offered a choice of GP practices to register with, and that the manager had respected individual preferences. Medicines were all stored in a lockable cupboard. Residents where able are encouraged and supported to look after their own medication within a Risk Assessment process. Some unlabelled medicines were found, although these were recorded on the Medicines Administration Record (MAR) chart. The record of medicines leaving the home for periods of social leave and those returning after the period of social leave were not complete for all residents. All staff administering medicines have received training from the supplying pharmacy. Staff are assessed as competent initially but there is no review of this competence. The medicines policy needs to be reviewed to reflect the The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 Page 13 availability of “Homely Remedies” in the home. No guidelines are available for the administration of those medicines that had been prescribed as being “when required”. The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 Page 14 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 Residents at Old Galleries are able to voice concerns about their care safe in the knowledge that their views will be respected. Policies, procedures and training of staff ensured that residents are safe and protected from abuse. EVIDENCE: The complaints procedure was clearly displayed on the notice board. Residents told the inspector that if they had a concern they “would discuss it at the resident’s meeting” or [the manager]. The record of complaints was seen. No complaints had been received in the previous 12 months. Certificates of attendance of a course on ‘The awareness and prevention of abuse’ were seen in the training file for all staff on the team. Information about ‘whistle blowing’ was seen on the resident’s notice board in a format that was easily to understand. It clearly stated their right to be treated with respect and what to do if someone was being abusive towards them. Interactions between staff and residents were warm, friendly and mutually respectful. The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 Page 15 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 The Old Galleries provides a comfortable environment, which could be improved by the installation of heating in the front lounge and increased access to the kitchen or increased access to beverage and snack making facilities. EVIDENCE: Old Galleries comprises a large terraced property with a front door onto the High Street, which afford residents easy access to the facilities available in Bideford. The home is in an area, predominantly of shops and its entrance is unassuming and in keeping with the area. The premises are spacious with adequate provision of bathrooms and wcs. Despite a shower and wc being out of order at the time of the inspection but which were scheduled for repair over the forthcoming weekend. The home is centrally heated although this does not include the front lounge area for which a heater was brought in during the inspection to ensure adequate heating. Residents can access both lounges and the dining area, however the kitchen was locked and residents can only access there when staff are present. There was a kettle in the dining area but no evidence of snacks and beverages in this area to enable residents to make beverages or snacks at time of their choice. The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 Page 16 The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 Page 17 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): 33, 34, 35 Whilst staffing levels meet the needs of the current residents, rosters should be maintained in accordance with the Regulations and show the level of managerial input. Residents are protected by the home’s recruitment policy and procedure. Staff at the home are scheduled to receive training directly related to the perceived needs of future service users. EVIDENCE: Inspectors arrived at the home and established that there were no staff on the premises. There were two residents on the premises, who informed the inspectors that the staff member on duty was next door at Bank House [this is a premises owned by the owners of Old Galleries and accommodating people under supported living]. After 10 minutes the staff member returned to Old Galleries. Half an hour later, the registered manager of Old Galleries and the Head of Care arrived and reassured the inspectors that this was not a common occurrence. This was further verified by residents who told inspectors that there was usually always a member of staff in the home with them. Rotas were available. These showed that staff worked between Old Galleries and Bidna House. At the present time Old Galleries is not staffed at weekends. This is because of the three people who reside there, one stays with relatives every weekend and the other two are content to return to Bidna at weekends. One of these residents previously resided at Bidna House and still has his room there, the other resident is accommodated in a room designated for respite care. Both residents confirmed that they were happy with this arrangement. The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 Page 18 The manager confirmed that this arrangement would only continue whilst residents were in agreement with it and that it was undertaken in the interests of residents rather than to make staffing easier. Whilst rotas showed the shifts worked by staff, it did not show the hours worked by either of the registered managers. The registered managers signed the rotas, however it was said that the signatures did not show that the managers had worked that shift but rather that they may have ‘popped in’. In accordance with Regulation 17(2), Schedule 4, a copy of the duty rosters of persons working at the home, and whether the roster was actually worked, must be maintained. The inspectors were informed that only one new staff member had been recruited since the last inspection. Examination of this staff member’s file showed that the home obtained two written references, had their identity confirmed by reference to birth certificate and driving licence and completed police checks as part of the recruitment procedure thereby ensuring that staff suitable to work with vulnerable adults. The training records relating to the head of care was examined. This showed that various courses `had been attended over the previous five years. The home has regular fire safety training to ensure the safety of residents. Records showed that the home operates a standard induction for new staff. This ensures that staff have an appropriate knowledge base to enable them to perform their duties. The home has a training schedule for 2006, which allows for staff to receive training each month on a variety of topics relevant to the client group at Old Galleries. These included the psychology of autism, Asperger’s Syndrome and Neurological Issues of Mental Health. In addition, the home is registered with the Autistic Accreditation Society, which is to provide specialist training for staff at the home. The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 Page 19 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): 39, 42 In order to measure the effectiveness of the home quality assurance and quality monitoring systems which regularly seek the views of residents should be undertaken. Health and Safety measures safeguard residents, staff and visitors to the home. EVIDENCE: In discussion the registered manager said that at the time of the inspection the home had not carried out a quality assurance audit. The last quality assurance report had been done more than a year ago. Evidence was seen showing that previous audits that had been done of the health and safety procedures in the home. Meetings had been conducted with residents on the running of the home. Residents told inspectors that they felt listened to by care staff. Care files demonstrated that care plans had been regularly reviewed with residents indicating they are consulted about their care. The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 Page 20 Certificates demonstrated that the electrical system had been totally re-wired in November 2004. Risk assessments were seen and had been regularly reviewed. All of the staff had an up to date First Aid qualification. First Aid equipment was readily available. A hazard analysis had been done covering food preparation, storage and kitchen procedures. Refrigerator and freezer temperatures had been carried out daily. Staff told the inspectors that fire training had been provided twice during the year. Accident records had been kept up to date. Labels and records showed that competent person had last checked electrical appliances. A senior member of staff holds the qualification for PAT testing of appliances and the certificate was seen which verified this. The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 4 x x x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score x x 2 3 3 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Old Galleries Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x DS0000022115.V253082.R01.S.doc Version 5.0 Page 22 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 YA20 Regulation 13(2) Timescale for action The registered person shall make 15/06/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The registered person shall maintain in the care home the records specified in Schedule 4. A copy of the duty roster of persons working at the care home, and a record of whether the roster was actually worked. This requirement had not been met since the last inspection on 18/9/05 and is repeated. 15/06/06 Requirement 2 YA33 17(2) Sch 4.7 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 Page 23 1 YA20 2 YA24 The medication policy for the home should be reviewed to reflect the non-availability of homely remedies. Clear guidelines should be available for the use of medication prescribed, “when required” and what strategies are to be used before their administration. The competence of staff administering medication should be regularly reviewed as part of the supervision process. In accordance with Standard 24.6 the lounge should at all times have sufficient heating to make in comfortable for use by residents. Residents should have access to the kitchen or increased access to beverage and snack making facilities. 3 YA39 Quality assurance systems should take account of the comments from residents and other stakeholders at least on an annual basis. A report summarising these findings and any necessary action, should be compiled and shared with the Commission, residents and other stakeholders. The Old Galleries DS0000022115.V253082.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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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