Inspection on 24/10/06 for Trafalgar House

This inspection was carried out on 24th October 2006.

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 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 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Trafalgar House 26/10/05

Trafalgar House 10/05/05

Trafalgar House 07/12/04

Trafalgar House 07/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Trafalgar House 9 Sutherland Avenue Bexhill-on-sea East Sussex TN39 3LT Lead Inspector Niki Palmer Unannounced Inspection 24th October 2006 2pm Trafalgar House DS0000021273.V312181.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 Trafalgar House DS0000021273.V312181.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. Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trafalgar House Address 9 Sutherland Avenue Bexhill-on-sea East Sussex TN39 3LT 01424 222911 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) www.caremanagementgroup.com Care Management Group Ltd (trading as CMG Homes Ltd) Vacant Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That the home is registered to accommodate up to seven (7) service users. That the service users are aged between 18 and 65 years upon their admission. That the category of service users admitted have a learning disability, not falling within any other category. 26th October 2005 Date of last inspection Brief Description of the Service: Trafalgar House is one of many homes owned by Care Management Group (CMG), which is registered to provide support and accommodation for up to seven adults with mild to moderate learning disabilities. Residents at this establishment also present with some challenging behaviour and mental health needs. The home is located in Bexhill-on-Sea and has good access to local amenities and public transport. There is a small car parking area to the rear of the property, which is primarily for the home’s people carrier, although on street parking is permitted for staff and visitors. The home is a detached three-storey property with a small garden to the rear of the property. It consists of six single bedrooms and one self-contained flat on the third floor, two bathrooms / shower facilities, a spacious lounge and separate kitchen and dining area. In addition there is office accommodation for the manager and staff. The layout and facilities within the home would not be suitable for those with reduced mobility or wheelchair users. Prospective residents and their relatives are provided with written information regarding the services and facilities provided at the home prior to admission. The home’s most recent inspection report is available on request. The home’s fees as of 19th October 2006 range between £1300 - £1900 per person per week dependent on needs. Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Trafalgar House will be referred to as ‘residents’. This unannounced inspection took place on Tuesday 24th October 2006 between 2pm – 7.30pm. Five male residents were accommodated on the day of the inspection aged between 31 and 46 years of age. All residents were at home on the day of the inspection. In order to gather evidence on how the home is performing, individual discussions took place with two residents and members of staff, whilst the majority of the inspection was undertaken with the acting manager of the home. Two care records were examined in some detail for the purpose of monitoring care. Other areas and documentation inspected included: the home’s pre-admission procedures, medication practices, the provision of activities, quality assurance systems, complaints procedure and the systems in place to safeguard residents from harm, staffing levels and the provision of relevant training. All communal areas were seen and two vacant bedrooms. One resident kindly showed the inspector their room. A pre-inspection questionnaire was received prior to the visit to the home. This provided the inspector with information relating to the premises, maintenance and associated records, details of the home’s policies and procedures, staffing details and relevant training. Five residents’ survey questionnaires were received by the inspector prior to the inspection, all of which had been completed with the support from members of staff. Following the inspection, telephone contact was made with 2 care managers and one person’s parents. Their views are reflected throughout this report. In order that a balanced and thorough view of the home is obtained, this report should to be read in conjunction with the previous inspection report carried out on 26th October 2005. What the service does well: Residents at this home are supported by a dedicated staff team who have a good understanding of the needs of individuals. Comments received from others in relation to the staff include: Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 6 ‘They are a good and very supportive staff team’ ‘The staff team are very upfront, open and honest about how they work’ ‘They’ve worked really hard with [the resident] over the years. I have no complaints’ Good systems are in place to ensure that all new potential residents will have their needs thoroughly assessed prior to admission. All prospective residents are given the opportunity to visit the home and meet with staff and other residents prior to moving in. A good variety of in-house and external leisure activities are available including: going to the cinema, swimming, pub, shopping, restaurants and holidays - some of which are abroad. Following a residents’ meeting a pool table and table tennis table was purchased in order to provide alternative inhouse leisure activities in addition to board games, art and crafts, computer games and TV/video/DVD’s. Residents confirmed that they would feel confident in raising any concerns or complaints directly with the home. What has improved since the last inspection? What they could do better: There are two requirements outstanding from the previous inspection report: - The home is required to ensure that at least 50 of care staff are qualified to at least NVQ Level 2 in Care. - Despite advice being taken from the fire safety officer in respect of the use of door wedges, they continue to be used. The home is required to address this matter in order to better safeguard the health and safety of residents and staff. In order for the staff to have a greater understanding and knowledge of working with people with learning disabilities and challenging behaviour/mental Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 7 health, additional staff training is required. These areas include: mental health, the use of physical intervention and epilepsy. Minor shortfalls have been identified in the home’s medication practices and procedures, which need to be addressed. The acting manager of the home must ensure that any complaints received are appropriately followed up. This must include a written letter of response to the complainant detailing the action that has been taken. Any alleged incidents of neglect, harm and abuse must be referred to the appropriate agency without delay. 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. Trafalgar House DS0000021273.V312181.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 Trafalgar House DS0000021273.V312181.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home has good systems in place to ensure that no person is accepted whose needs cannot be met. EVIDENCE: The acting manager of the home confirmed that the home’s Statement of Purpose and Service Users’ Guide are currently in the process of being updated to include the current details of the management structure and staffing levels. With the exception of one resident’s questionnaire who had been placed at the home on an emergency basis, most residents felt as though they received enough information about the home prior to admission in order to support their decision of where to live. In most cases they also confirmed that they had the opportunity to visit the home and meet with other residents before moving in. Concerns have been raised in the past regarding the home’s admission procedures – namely the compatibility of residents within the home. CMG employs a team of centrally based assessment referral officers, who are responsible for considering and assessing all initial referrals for each of the care homes across the South East region alongside the acting manager. The acting manager confirmed that there has only been one new admission to the home since the last inspection. A detailed pre-admission assessment form was seen for this person and albeit that it was noted to be sufficiently detailed and Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 10 there was clear evidence to demonstrate that this had been undertaken with the person’s previous place of residence, family members and care manager, this person’s primary care need is mental health; they do not have a learning disability. Clear evidence was provided however, during and after the inspection through discussions with relatives and the person’s care manager, that the home is working well with this person and can indeed meet their assessed needs. Trafalgar House DS0000021273.V312181.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9, Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s care planning procedures could be improved in order to make them easier to follow and understand. Residents are supported well by the home to make individual choices regarding many aspects of their lives. EVIDENCE: All residents have an individual plan of care in place, two of which were examined in some detail. Whilst on the whole individual care needs had been identified and there was guidance in place for staff to follow, the current format is difficult to read and understand as the home currently uses a number of different recording methods; a ‘working’ care plan, a separate file for correspondence and history, separate daily records and another file for risk assessments. Albeit that staff spoken with appeared to have a good understanding of residents’ needs, it is strongly recommended that the current care planning format is revised and simplified in order to make them more user friendly. Relatives confirmed that they receive monthly keyworker reports by the home, which enable them to keep up to date. Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 12 All of the returned residents’ questionnaires confirmed that all of the residents feel that they are usually supported to make their own decisions about many aspects of their lives for example what to do each day, what to eat and holidays etc. Relatives and care managers also confirmed that where there is difficulty in supporting residents in this area, they are consulted and involved in this process. Residents currently living within the home are reasonably able to do many things for themselves e.g. their own laundry and some cleaning duties. Through discussions with staff it emerged that despite residents’ capabilities, staff tend to do most other things for them: meal preparation and washing up, making drinks and other cleaning duties within the house. One resident spoken with told the inspector that they would like to be more involved in certain aspects e.g. meal preparation. The home is required to consult with residents regarding daily activities and chores within the home that they may wish to become involved in. Following consultation, residents should be encouraged through choice, to become more involved in the day-to-day running of the home. All of the residents are encouraged to take responsible risks where necessary in order to promote their independence. Whilst a number of core risk assessments for activities of daily living are in place, it was noted that a high proportion of them were standardised templates, which did not give a clear picture of why the risk assessment was being completed or what the overall level of risk is in relation to the individual. This indicates that some risk assessments are being completed as a matter of course rather than being person centred and specific to individuals. The home is required to ensure that key risk assessments are reviewed, updated and detailed in order to make them more person centred. Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents lead a varied and fulfilling lifestyle, which encourages them to maintain and develop their life experiences and independence. EVIDENCE: Only a small number of residents have planned daily activities in place, e.g. day services and/or college. The home is currently in the process of supporting two residents to seek possible employment and/or day service provision. The home was noted to be reasonably quiet over the duration of the inspection, which staff confirmed was normal. Most residents choose to spend time in their own bedrooms if they are not out and about. Residents spoken with and through evidence provided within the returned questionnaires indicate that there are a number of different opportunities for residents to participate in their local community. Examples of these include: going to the cinema, swimming, pub, shopping, restaurants and holidays some of which are abroad. Following a residents’ meeting a pool table and Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 14 table tennis table was purchased in order to provide alternative in-house leisure activities in addition to board games, art and crafts, computer games and TV/video/DVD’s. On the day of the inspection three residents were receiving one-to-one aromatherapy, which is arranged on a monthly basis by the home and is carried out by an external aromatherapist. Residents and others spoken with stated that visitors are always made to feel welcome at the home and that there are no restrictions placed on visiting times. Telephone contact as well as regular visits to the home are also encouraged and supported. Throughout the duration of the inspection all staff were observed to knock on residents’ bedroom doors prior to entering and address them by their preferred term. All bedroom doors are fitted with individual locks. Most residents, as per their risk assessment choose to keep their rooms locked when they are not at home. All meals are prepared within the home by care staff based on a two weekly rotational menu. The acting manager confirmed that the home is currently in the process of revising the menus in order to offer residents more of a variety based on choice and individual preferences. These will be examined at the next inspection. All residents spoken with said that the provision of food within the home is usually of a good standard and that they do on occasions eat out or order in takeaways. One person commented that their favourite food is a cooked breakfast, which is usually prepared by care staff at weekends. Records of all meals are kept. Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Additional training is required for all staff in order to meet the personal healthcare and psychologocal needs of residents. Medication practices are sufficient. EVIDENCE: All residents are registered with a local GP and dentist and are supported to all healthcare appointments as necessary. Specialist advice from the Community Learning Disability Team (CLDT) and more recently the Community Mental Health Team (CMHT) is requested on an individual basis. At this present time, due to the capabilities of residents accommodated, only a low level of personal care is required by care staff, however due to the more complex psychological support that individuals need, the home is required to ensure that additional mental health training is provided to all staff. A number of residents may occasionally present with some challenging behaviour. Whilst care staff spoken with were clearly able to talk about the non-invasive procedures that they would use to de-escalate any potentially difficult situations, the home is required to ensure that individual behaviour Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 16 management guidelines are in place within plans of care. In addition to the above, it may on some occasions be necessary for care staff to intervene on a more physical basis (restraint). Whilst some staff have received the appropriate training, not all have. It is further required that up to date training is provided to all staff working with residents who may at times require physical intervention. Two of the residents living at the home have epilepsy and whilst it was pleasing to note that some staff have received training in this area including the administration of emergency medication, individual epilepsy management guidelines were noted to be brief and therefore not provide staff with clear and detailed guidance. It also emerged through discussions with care staff that they were unaware of the different types of seizures that individuals have. The home is required to ensure that epilepsy management guidelines are clear, precise and include: a brief history of the person’s seizures, a description of what form the seizure takes and clear instructions for staff to follow in the event of a seizure occurring. Additional training must be provided to all staff. The home’s medication records and storage systems were inspected. The home uses a pre-packed blister pack, which is delivered by the local pharmacy on a monthly basis. Only members of staff who have received the relevant training and have been assessed as competent in the administration of medicines are able to carry out this task, whilst only senior members of staff hold responsibility for the reordering and returning of medicines to the pharmacy. Whilst all medicines were found to be appropriately stored in the main office with records mostly maintained, the home is required to ensure that all medication administration records are clear and legible and that a medication error policy and procedure is in place. This should encourage staff to report any errors no matter how minor. This will help to support the home to identify any faults in their current procedures and future training needs for staff. The home is further required to ensure that clear guidelines are in place for all medicines that are prescribed on a PRN basis (as and when). This must include tablets and topical creams. Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has good systems in place to ensure that all complaints are dealt with appropriately, however the home’s procedures need to be followed. Clear procedures are in place to protect residents from harm, neglect and abuse although immediate action must be taken. EVIDENCE: The home has a revised complaints policy and procedure in place, which was seen on the day of the inspection. Residents confirmed that they would feel confident in raising any concerns directly with the home. One complaint has been received by the home since the last inspection, which was made by the District Council in relation to an overhanging tree. This was promptly dealt with by the acting manager, however there was no record of this available for inspection. The home is required to ensure that all complaints are responded to in writing as per the home’s procedure. Records must be kept. No complaints have been received by the CSCI since the last inspection. The home has a detailed Adult Protection and Whistle-blowing policy in place. There have been two adult protection alerts made since the last inspection, however in one instance there was a delay of informing Social Services. The home is required to ensure that all allegations of potential harm, neglect and abuse are reported to Social Services without delay. Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Trafalgar House presents as a clean, well-maintained and homely place to live, however residents and staff will be better safeguarded when action is taken to address the shortfalls identified in respect of fire safety. EVIDENCE: Accommodation is provided over three floors, which presents as comfortable and homely throughout. All rooms are for single occupancy. Residents confirmed that they have been supported to personalise their own bedrooms with furniture and decor. Since the last inspection the outside of the house has been painted and some new windows have been installed. In addition, new fencing has been put up around the perimeter of the house and the smoking room has been changed into an office for staff where medication is now stored. An additional shower facility has also been installed on the ground floor. Approximately 18 months ago, an additional bedroom was created on the third floor with en-suite facilities and its own kitchen area, however due to fire Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 19 safety issues, this kitchen is not permitted to be used. This room is currently vacant and was viewed on the day of inspection. Concerns were raised at the previous inspection regarding the use of door wedges in the home. Despite the home seeking advice from a fire safety officer who recommended that all fire doors are fitted with self-closing mechanisms, this remains outstanding. The home is required to comply with the fire safety officer’s report in respect of this. All areas of the home that were viewed on the day of inspection were noted to be clean and well-maintained. Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported and protected by the home’s robust recruitment procedures. Sufficient numbers of staff are employed to meet the assessed needs of residents, however both residents and staff would benefit from additional staff training. EVIDENCE: In addition to the acting manager, the home employs a total of 16 care staff and one administrative person. Only four have achieved at least NVQ Level 2 in care, whilst a further four are currently working towards this. The recruitment files for two newly appointed members of staff were examined. It was pleasing to note that application forms were sufficiently detailed, two satisfactory written references had been obtained and there was evidence of a PoVA First check and Criminal Record Bureau (CRB) check in place. The acting manager confirmed that all new staff undertake a TOPSS induction. The inspector informed the acting manager of new legislation, which relates to the Common Induction Standards. These replaced TOPPS in September 2006. The home is required to work towards implementing these. Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 21 Staff confirmed that training courses are mostly in-house. Training within the past 12 months for some staff includes: food hygiene, moving and handling, supervision skills and emergency first aid. It was noted however that a number of staff are still in need of refresher training for health and safety, fire training, food hygiene, first aid and moving and handling. As the acting manager has recognised this and is in the process of taking the appropriate steps to address this, a requirement has not been made in respect of this, however this will be followed up at the next inspection. Since the last inspection clear supervision structures have been put into place. This was confirmed by staff. Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally run in the best interest of residents, however a more structured quality monitoring system would enable management to monitor the success of the home in meeting its aims and objectives. EVIDENCE: The acting manager has been in post since May 2005. Prior to this he was appointed as the deputy manager and has worked for CMG since 2000. He has obtained NVQ Levels 2 and 3 and is currently working towards NVQ Level 4 in management. He aims to have completed this and commence his Registered Manager’s Award by January 2007. He has submitted an application to the CSCI to become registered as the manager as per the last inspection report. He is strongly supported in his role by two deputy managers and administrative support. Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 23 CMG have provided the home with a quality assurance manual, which the manager has begun to implement alongside the regional operations manager. The home’s progress in relation to this will be followed up at the next inspection. The home has recently been provided with a revised copy of CMG’s policies and procedures. Whilst those that were seen were considered to be of a good standard and appropriate to the needs of the residents, it is recommended that a quick reference index guide is placed at the front of the file in order to make them more accessible to staff. Evidence provided within the home’s returned inspection questionnaire identified that regular health and safety checks are carried out including fire safety, emergency lighting, gas installation, electrical portable appliances tests and emergency call systems. As already mentioned, the home is required to take the appropriate action in respect of installing self-closing mechanisms to all fire doors. Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 1 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 2 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 1 2 X 3 X 3 3 X 2 X Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA8 Regulation Requirement Timescale for action 31/01/07 2. YA9 3. 4. 5. YA19 YA35 YA19 YA19 YA35 16(2)(h)(m) That the home consults with residents regarding daily activities and chores within the home that they may wish to become involved in. Following consultation, residents should be encouraged through choice, to become more involved in the day-to-day running of the home. 13(4)(a-c) That key risk assessments are reviewed, updated and detailed in order to make them more person centred. 12(1)(a) That specialist mental health 18(1)(c)(i) training is provided to all staff. 12(1)(a)(b) 12(1)(a) 18(1)(c)(i) That individual behaviour management guidelines are in place. That up to date training is provided to all staff working with residents who may at times require physical intervention. That individual epilepsy management guidelines are clear and precise. These must include a brief history of the person’s seizures, a description DS0000021273.V312181.R01.S.doc 31/03/07 31/01/07 31/01/07 31/01/07 6. YA19 YA35 12(1)(a)(b) 31/01/07 Trafalgar House Version 5.2 Page 26 7. 8. 9. YA20 YA20 YA20 13(2) 17(1)(a) Sch3(k) 13(2) 17(1)(a) Sch3(k) 13(2) 17(1)(a) Sch3(k) 22(3)(4) 10. YA22 11. YA23 13(6) 12. YA24 YA42 23(4)(a) 13. YA32 18(1) 14. YA35 18(1)(a)(c) of what form the seizure takes and clear instructions for staff to follow in the event of a seizure occurring. Additional epilepsy training must be provided to all staff. That all medication administration records are clear and legible. That a drug error policy and procedure is devised and implemented. That clear guidelines are in place for all medicines that are prescribed on a PRN basis (as and when). This must include tablets and topical creams. That all complaints received by the home are responded to in writing as per the home’s procedure. Records must be kept. That all allegations of potential harm, neglect and abuse are reported to Social Services without delay. That in accordance with advice from the fire safety officer, selfclosing mechanisms are fitted to all fire doors [outstanding from 01/12/05]. That 50 of care staff are qualified to at least NVQ level 2 in care [outstanding from 01/01/06]. That the home begins to work towards implementing the new Common Induction Standards replacing TOPPS. 24/10/06 31/12/06 31/12/06 24/10/06 24/10/06 31/12/06 31/03/07 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 27 No. 1. 2. 3. 4. Refer to Standard YA6 YA20 YA20 YA40 Good Practice Recommendations That the current care planning format is revised and simplified in order to make them more user friendly. That additional lighting is provided in the area where medicines are stored and administered. That all handwritten entries on the MARS are countersigned in order to minimise the potential for human error. That a quick reference index guide is placed at the front of the home’s policies and procedures file in order to make them more accessible to staff. Trafalgar House DS0000021273.V312181.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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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