Inspection on 25/07/05 for Three Gates

This inspection was carried out on 25th July 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Three Gates 22/11/06

Three Gates 12/01/06

Three Gates 16/03/05

Three Gates 19/08/04

Three Gates 03/02/04

Three Gates 15/05/03

Three Gates 26/11/02

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

CARE HOME ADULTS 18-65 Three Gates 62 Cloves Hill Morley Derbyshire DE7 6DH Lead Inspector Tony Barker Unannounced 25/07/05 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 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 Stationary 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. Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Three Gates Address 62 Cloves Hill Morley Derbyshire DE7 6DH 01332 880584 01322 880584 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) United Response Olivia Beaumont Care Home 4 Category(ies) of LD - Learning Disability registration, with number of places Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16 March 2005 Brief Description of the Service: Three Gates is a detached bungalow in a rural position on the edge of a village. Service users are provided with spacious accommodation and single rooms. There is a large rear garden. Three Gates offers personal and social care to people with a severe learning disability with associated conditions that may include autism, sensory disability or challenging behaviour. Activities are planned to meet individual needs, and service users experience a wide range of community-based activities. The staffing levels have been set high in order to achieve this. Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 5.0 hours and was a routine unannounced inspection. The last inspection took place in March 2005 and was an unannounced inspection focussed purely on medicine policies and procedures within the Home. This inspection was the inspector’s first visit to the Home. The Acting Manager and her line manager were spoken to, records were inspected and there was a tour of the premises. Service users’ disabilities were such that they were unable to speak except on a single word level. However, they had varying degrees of non-verbal communication with the inspector. The focus of this inspection was on progress made on the requirements and recommendations made, and those standards not assessed, at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: The registered person must update and improve some of the Home’s documents to ensure that full information about the Home is available and service users are fully protected by adequate adult protection and staff recruitment procedures. Improvements were needed to some areas of the building. Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 Page 6 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. Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 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 standard(s) 1 & 5 Full information about the Home was not available in order for service users and their families to make an informed choice about where to live. EVIDENCE: United Response’s Service Users’ Guide had been updated in August 2004 but was still not personalised to this Home. The intention is that it will include photographs of staff and of the Home and will be complete within weeks, the Acting Manager said. There was a contract in place, between United Response and the relevant funding agency, for each service user. However, the Home’s Terms & Conditions of Residency was still to be personalised to the Home. Some relatives have received a non-personalised copy and service users will receive theirs when personalised. Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 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 standard(s) 7, 8 & 9 Service users were making decisions about their lives with assistance from staff and advocates. They were participating in the running of the Home as far as their disabilities allowed and were being supported to take responsible risks. EVIDENCE: Observations throughout the inspection showed that service users, regardless of high levels of impairment and poor communication skills, were encouraged to make decisions about their lives and make specific choices. Staff had developed ways to enable them to understand the expression of preferences and choices in very individual ways. Staff had had basic training in the use of Makaton sign language. There was good contact from family and friends of service users – they acted as advocates. All service users were closely involved in individualising their bedrooms. Pictorial symbols were seen in these rooms. Service users all participated in the day-to-day running of the Home to varying levels – shopping, baking and a range of domestic tasks. Written care plans did much to guide and support staff in appropriate behaviour management programmes. Files contained comprehensive risk assessments for a wide range of activities with potential risk attached. These Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 Page 10 included absconding and eating inappropriate objects. There was a missing persons policy. Service users were being supported to take considered and responsible risks as part of an individual lifestyle. Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 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 standard(s) 13,16 & 17 Service users benefited from a good range of fulfilling leisure activities both within the Home and in the wider community – of which they were a part. Service users’ involvement in daily routines reinforced their personal development. They were offered a healthy diet. Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 Page 12 EVIDENCE: The Acting Manager reported that service users had limited contact with the neighbours but regularly used local facilities – for example, hairdressers of their choice, cinema, swimming baths and meals out. Staffing levels were weighted to provide 1-to-1 support on each individual’s personal day. It was reported that service users used public transport such as buses, taxis and trains - although the Home had it’s own transport which service users mostly used. Service users were reported to be involved in a wide range of leisure activities and records viewed supported this. These activities were based in general community facilities and in places where the service users could spend recreational time with others with similar needs. Leisure opportunities within the Home also took account of individual preferences and included sensory, table top games and craft activities and table tennis. There were plans for a heated outdoor spa. The findings throughout the inspection showed that daily routines promote choice and independence. Due to the need for structure and patterns dictated by the service users’ autism, life at the Home was quite structured, particularly at the beginning and end of each day. A relaxed atmosphere was noted during this inspection. Service users had access to all areas of the house and spent varying amounts of time in their own rooms. The large garden area was freely accessible and safe for service users. There were plans for a new fence to address one service user’s absconding. The kitchen was domestic in style and well set out. Service users were involved, with staff, in preparing and serving some meals. All four service users were reported to be able to make snack meals and hot drinks safely. Appropriate food supplies were available at the time of inspection. Staff and service users go out and buy foods locally on a weekly basis and ‘top up’ more frequently. It was reported that service users’ dietary preferences had been identified over a period of time and were catered for within the daily cooking plan and recorded in individual files. Mealtimes were broadly at regular times, although this was dependent on activities. Service users ate with staff. Themed evenings were held at the Home each Saturday and service users had tried a variety of traditional and international foods. All four service users regularly ate out on personal 1-to-1 days. Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 20 Service users were being protected by the Home’s policies and procedures for dealing with medicines. EVIDENCE: It was noted that the service users had a range of mental and physical disabilities. From discussion with the Acting Manager it was clear that there was a good working relationship with the local community team. There had been involvement from a psychologist and a speech therapist in the past. Other aspects of service users’ healthcare were not assessed at this inspection. The handling, administration and recording of medicines used when service users are on holiday, or on trips to relatives, had been improved since the last inspection. Evidence of this was seen on Medication Administration Record (MAR) sheets and in discussion with the Acting Manager. However, there was still an example of a handwritten entry on a MAR sheet that had not been checked, countersigned and dated. The Acting Manager said that United Response is organising staff training, by an accredited trainer, on the safe handling of medicines. Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 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 standard(s) 23 The Home’s policy on Adult Protection was not fully protecting service users from abuse. EVIDENCE: The Home had an extensive policy and procedure on prevention of abuse linked to the statutory procedures and prepared by United Response. However, there was no explicit reference to Social Services, as lead agency, being contacted in the event of suspicion of abuse and before any investigation being initiated. Records indicated that all staff had received training on prevention of abuse and the Acting Manager stated that all staff are issued a copy of the Home’s whistle blowing policy on induction. All staff were attending SCIP training annually: this provided staff with skills to appropriately manage aggressive behaviour in adults with learning disability. There had been no allegations or incidents of abuse at the Home in the last 12 months. It was reported that incidents of aggressive behaviour at the Home were infrequent, as were instances of self-harm. The Acting Manager said that the Area Service Manager was appointee for service users’ finances. Records of incoming and outgoing payments of service users’ mobility allowance were available. A new risk assessment on financial abuse had been developed because of the introduction of debit cards, by the bank, for each service user. Bank statements and account books were seen. Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 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 standard(s) 24 & 26 Service users were benefiting from a homely and comfortable environment although attention was needed to some redecoration. EVIDENCE: The building was being rented from a housing association. A tour of the premises showed that the Home was generally well maintained. However, there was rot in the wooden window sills in the lounge, both inside and outside. There was no opening window in this room thus potentially leading to condensation. The Home was in keeping with a domestic setting and was decorated and furnished to a pleasant and comfortable standard throughout. It was reported that the service users were involved in choosing the colour schemes. Some redecoration of painted ceilings and walls was needed due to condensation. Bedrooms were very well individualised and were furnished and comfortable. They were locked at the request of service users. Each service user had access to a lockable storage area although not all were able to operate the lock without help. The level of lighting in the bathroom was rather low and could increase the risk of accidents in here. Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 & 35 The Home was not fully protecting service users by means of required staff recruitment procedures. Service users’ needs were being met by a well trained staff group. EVIDENCE: The Acting Manager confirmed that there was still a stable staff group and that there were no longer any staff vacancies. There were ten staff – seven of these had attained a National Vocational Qualification (NVQ) at level 2 or above. Staffing hours provided were set at a high level to reflect the high dependency needs of the residents. The staff rota was not examined on this occasion. Two staff files were seen and these included all the records required by the previous Schedule 2 of the Regulations. The Acting Manager was informed of changes to Schedule 2 that had taken place in 2004 - which meant that the Home was no longer meeting Regulation requirements. Signed staff contracts were seen. Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 Page 17 Discussion with the Acting Manager, and records seen, indicated that staff had attended a wide range of training sessions in the last year, including core mandatory topics and those relating to the individual needs of service users. Examination of staff files demonstrated that newly appointed staff were in the process of completing the Home’s induction and foundation training - this had been structured on the Learning Disability Award Framework (LDAF). The Acting Manager explained that the Home used to receive a ‘training matrix’ staff group record and individual staff training records, from United Response HQ. She said that United Response is supportive of staff training. Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Service users were benefiting from the Home’s self-monitoring and staff awareness of risks. EVIDENCE: The Registered Manager was temporarily absent from her post. The Acting Manager has agreed to supply the Commission with an application for registration. Team meetings were being held every six weeks. These, along with staff supervision sessions, were used to reinforce the Home’s policy and procedures on adult protection as well as other policies and procedures. Service users’ records were being securely kept in a locked office. All practices in the kitchen were seen to be safe. Other aspects of the Home’s conduct and management were not assessed. Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 Page 19 Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 Page 20 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 2 x x x 3 Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x x 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Three Gates Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 Page 21 No 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 1 Regulation 5(1)(2) Requirement The registered person must produce a Service Users Guide, personalised to the Home, and supply a copy to each service user. The Home must have a policy/procedures on Adult Protection in line with the DoH guidance, No Secrets. The registered provider must carry out refurbishment of the lounge window sills and redecoration of other parts of the building affected by damp. The level of lighting in the bathroom must be increased. The registered person must audit all staff files against the revised Schedule 2 of the Regulations and ensure that the contents are as required. Timescale for action 1 November 2005 1 December 2005 1 March 2006 2. 23 12(1)(a) 3. 24 23(2)(b) (d) 4. 5. 27 34 13(4)(a) (c) 19(1)(b) Sch 2 (revised) 1 October 2005 1 December 2005 6. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Three Gates Refer to Good Practice Recommendations C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 Page 22 1. 2. Standard 5 20 3. 4. 35 37 The registered person should produce written Terms & Conditions of Residency, personalised to the Home, and supply a copy to each service user. If the Medication Administration Record (MAR) chart is handwritten or altered by a member of staff this should be checked, counter signed and dated by a second member of staff.(This was a recommendation from 16 March 2005) The registered provider should consider providing a ‘training matrix’ staff group record and individual staff training records to the Home. The Acting Manager should make application to become the registered manager of Three Gates. Three Gates C02 C52 Three Gates S20109 V240963 250705 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road, Derby DE1 3QT 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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