Inspection on 19/07/05 for Underhay House

This inspection was carried out on 19th July 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Underhay House 16/07/08

Underhay House 03/08/07

Underhay House 13/09/06

Underhay House 26/01/06

Underhay House 27/02/05

Underhay House 28/09/04

Underhay House 27/01/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Honeybourne House

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

CARE HOME ADULTS 18-65 Underhay House 639-641 Muller Road Eastville Bristol BS5 6XS Lead Inspector Paula Cordell Announced 19 July 2005 09:30 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. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Underhay House Address 639-641 Muller Road Eastville Bristol BS5 6XS 0117 9519094 01275 372151 info@freewaystrust.co.uk Freeway Trust 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) Miss Claire Anne Hayward Care Home for Younger Adults 12 Category(ies) of LD Learning disability for 11 registration, with number MD Mental Disorder for 1 of places Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Not applicable Date of last inspection 27 February 2005 Unannounced Brief Description of the Service: Underhay House is a care home that is registered with the Commission for Social Care Inspection to provide personal care for up to twelve persons, eleven with a learning disability and one specific person with a mental disorder, all aged between 18-64 years. The home is operated by Freeways Trust Ltd, a non-profit making organisation that has a number of care homes within the local area. There is a satellite home for three people at 224 Glenfrome Road that is close to Underhay House and which is registered with the Commission for Social Care Inspection. Both homes are managed by the same person Miss Claire Hayward. The accommodation comprises of two mature terraced houses based over three floors. Access to the upper floors is by means of stairs only. The home is situated in a residential suburb of Bristol on a busy road. Public transport is available close to the house and there are local shops opposite as well as a large supermarket within a quarter of a mile of Underhay House. Underhay House is within quarter of a mile of the M32, an urban motorway that links to Britains motorway system. Underhay House also accommodates a pet cat. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection. The purpose of the visit was to review the progress to the requirements and recommendations from the unannounced visit in February 2005. The home has demonstrated compliance to most or is working towards the requirements and recommendations from the previous inspection. The outstanding requirement relates to the refurbishment of the environment. It was the provider’s responsibility to produce a refurbishment/repairs plan for Underhay and a copy to be submitted to the Commission for Social Care Inspection. The provider failed to send this information prior to the inspection and was contacted during the visit and has agreed to send this information within 24 hours. This was received in the office on the 26th July 2005 detailing the plans for the refurbishment of the property. There have been no additional visits during this period. The home has been keeping the Commission for Social Care Inspection informed of incidents that affect the wellbeing of the individuals living at Underhay House and the provider has sent monthly appraisals of the service. This information was used to plan the inspection process. The inspection was conducted over 8 hours. The inspector had an opportunity to meet with nine of the twelve residents, four members of staff, the deputy and the manager. A follow up visit was completed on the 26th July 2005. The methodology used during this inspection included viewing care records and other relevant documents required of a care home and a tour of the home. Residents were actively encouraged to participate in the process by the staff on duty. The inspector received one relative and one resident questionnaire. The inspector would like to take this opportunity to thank the team and the residents for their welcome and their assistance in the inspection progress. What the service does well: Underhay provides individualised packages of care to twelve people in a homely environment. There was a strong commitment to empowering individuals and supporting them in their chosen lifestyle promoting independence and community participation. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 6 The home liaises with other professionals to provide a quality service complimenting the skills of the staff team. There is a strong commitment to having a trained staff team. There is an ongoing package of training from the commencement of employment which, includes a comprehensive induction and the Learning Disability Award Framework and then staff progress on to complete a National Vocational Award. Training was based on the care needs of the individuals living in the home. What has improved since the last inspection? The home is fully staffed and additional staff are employed which are above the minimum staffing to provide opportunities for individuals to access the community and meet their support needs. Residents and staff saw this as positive. Staff stated that this ensures that care is consistent and delivered by familiar staff and residents stated that there have been more opportunities to go out. Since the last inspection the home has devised a statement of purpose and a service user guide. There was evidence that this has been discussed with both the residents and the staff team. Residents now have an up to date and accurate complaints procedure, which clearly explains the procedure and the appropriate contacts within Freeways Trust Ltd. The manager has developed a training plan for all staff based on the needs of the individuals living in the home. This has included training on adult protection which staff are planning to complete in August 2005. This is in response to a requirement and the home is within the agreed timescale. The manager and staff stated that a review of visits by residents from another home has been undertaken. Residents were involved in the process. Staff stated that the residents from Glenfrome Road now telephone to ask if they can visit and visits are kept to a minimum. The provider, in addition, monitors this during the monthly visits. There have been no regulation 37 reports sent to the Commission for Social Care Inspection in relation to incidents occurring in Underhay involving an individual from Glenfrome. This was in response to a requirement from the inspection in February 2005. Residents and the business are now protected by adequate insurance. A current certificate was seen during the course of the inspection. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 7 What they could do better: There are a number of requirements and recommendations but this should not detract from the high level of satisfaction expressed by the residents or the commitment and the dedication of the staff team. Residents and relatives would benefit from having more information relating to the staffing in the statement of purpose, which clearly states how the home is to be staffed on a daily basis. Residents would benefit from the home devising a home’s care plan, which clearly describes how the staff should support them based on the Social Service’s plan of care. In addition residents should be given an opportunity to formally review their plan of care with relatives and other professionals where appropriate as stated in the statement of purpose on a six to twelve monthly basis. The home must maintain a record of all food offered to individuals living in the home. This would further evidence that residents are having a nutritious and varied diet offering individuals choice. Residents would benefit from having a refurbishment programme of decoration and repairs enhancing the homely appearance. Carpets were worn and decoration was looking tired throughout the home. Toilets throughout the home and one sink in a bedroom had large deposits of lime scale. These would benefit from a deep clean or being replaced. The follow up visit on the 26th July 2005 provided evidence that this deep clean had in fact taken place. Residents and staff would benefit from having more ventilation in the kitchen area. Residents and significant others including relatives would benefit from being involved in a quality audit initiative which would inform the business plan of the home. Residents must be protected by a thorough recruitment procedure, which includes obtaining information about staff’s identification and copies held in the home. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,5 Residents are given information about the home and a contract to enable them to make a decision to move to Underhay House. The home is meeting the assessed needs of the individuals. EVIDENCE: The home has a statement of purpose and a service user guide. The home has demonstrated compliance to amend the information about the changes in the named provider and details about the Commission for Social Care Inspection. The information was accessible written in plain English and included pictures. Copies had been made available to staff and residents. Further evidence had been seen that the statement of purpose had been discussed at a recent staff meeting. The manager stated that a copy had been attached to the notice board in the lounge but had gone missing. The manager has agreed to offer all residents a copy. The statement of purpose requires a minor amendment to include the daily minimum staffing arrangements for the home. The manager stated that the home should have a minimum of three staff in the home during the day. This should be included in the statement of purpose. The manager has agreed to Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 11 complete this over the next few days and send a copy to the Commission for Social Care Inspection. The inspector saw many examples of the staff team demonstrating the capacity to meet the residents’ specialised needs. Underhay is registered to accommodate and provide personal care for younger adults with a learning disability. It was evident from care records, discussions with staff and residents that several individuals also have complex physical, psychological and communication needs. There was evidence that the Community Learning Disability Team including the consultant psychiatrist and a behaviour team was supporting the home, staff and the individuals. This is seen as good practice and demonstrated a multi-disciplinary approach to the care of the individuals. Training will be discussed later. However, it was evident that the training was planned around the care needs of the individuals living in the home. The inspector was informed that one individual uses British Sign Language. Training was planned for later in the year for a number of staff to attend a course to improve communication. However, it was evident from talking with the resident and the staff that the individual could make themselves fully understood. Evidence was provided that a translator had been used when the individual had attended appointments where technical jargon was used and where the staff did not have the expertise in the signs for this particular activity. This is seen as good practice. The manager stated that two of the residents living in the home are being reassessed by a Social Worker as one individual has requested a move to independent living and a quieter environment, and the home is not suitable for another individual due to interpersonal relationships within the group and the affects this is having on the group dynamics. The team were of the opinion that the home was not suitable to meet the long-term needs of this individual. This is seen as good practice where the home ensures that they can continue to meet the needs of the individuals and their aspirations. Contracts were seen on individuals’ files and met with the legislation. These were updated annually to include the changes to the fees. This is good practice. These clearly stated what was not included in the fee and any additional costs. Residents contribute part of their disability living allowance to the running costs of the vehicle. Residents (where able) had signed the contracts. The inspector reviewed three of the five standards and the home has demonstrated a good understanding of the legislation. The other two standards had not been assessed on this occasion these have been assessed as met on previous inspections. The home has not had a new admission in the last twelve months. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 12 Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 13 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) 6,7,8,9,10 Residents are actively involved in the planning of their care on a monthly basis, however, the home must develop their own plan of care expanding that of the placing authority involving relatives and other professionals based on the wishes of the individual. EVIDENCE: A random selection of care plans were viewed. There was a lack of information to determine how the home was meeting the assessed care needs and the plan of care drawn up by the placing authority. The home works from the plan of care drawn up by the Social Worker, which lacks any real measurable outcomes on how the plan is to be implemented by the home or by whom. For example the Social Worker’s plan states to offer the individual opportunities to use the community- there was evidence that the home was working towards this goal via the monthly key worker reviews but a full review would have been difficult as the information was too broad to determine whether the home was meeting the specific individual’s needs. Residents confirmed their involvement in the planning of care via the monthly key worker meetings. These reviews included reviewing activities that had Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 14 been undertaken and discussing future plans for the forthcoming month, a review of health and discussions on general well being and a health and safety check of the individual’s bedroom. These were positively written and evidenced that the individual was the focus of the care delivery. Whilst the monthly reviews were taking place, two residents had not had a review involving relatives and other professionals where relevant. The statement of purpose clearly described the process of reviews, which was monthly by the key worker with a six to twelve monthly review involving relatives where relevant, based on the wishes of the individual. Both staff and residents were clear about the key worker role and spoke positively about the relationships that they had built. All staff spoken with had a good understanding of their roles and the care needs of the residents. The inspector observed positive and inclusive communication towards the individuals living in the home. Risk assessments were evident in care files. These included bathing, accessing the community and activities in the home. Care plans included positive strategies for dealing with challenging behaviour including triggers and techniques for supporting individuals giving staff clear guidance. The home had sought support and guidance from the Community Learning Disability Team, Psychology and the Behavioural Team for specific individuals. This is good practice. Records were held securely. Residents were observed reading their care files at leisure in addition residents had signed their plans of care, reviews and risk assessments. It was noted that they were aware not only did they have the right to read their care records but they also demonstrated that they were aware of the confidentiality of other residents’ files. Staff on duty confirmed this information at the time of the inspection. They also displayed their own awareness for confidentiality when discussing residents. In conclusion, whilst in part the standards are met. The home must develop their own care planning system and ensure that the reviews occur as stated in the statement of purpose. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 15 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) 11,12,13,14,15,16,17 Residents are leading full and active lifestyles based on choice. There is an emphasis on encouraging individuals to make choices and be as independent as possible. EVIDENCE: Residents were observed actively planning their day and making arrangements with staff. Residents told the inspector that they had lots of opportunities to go out with staff and some independently. Residents were keen to share information about trips out with the staff, family and the planned holiday. Residents stated that they had a choice of destinations for this year’s annual holiday and one group was going to France and the other Cornwall, others stated that they also continue to enjoy family holidays. One of the individuals was away for the month of July in Canada visiting relatives. A resident stated that there has been an increase in opportunities to go out with the increase of staff and the availability of drivers. The manager stated that the home has actively tried to recruit staff that can drive the home’s vehicle. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 16 Timetables indicated that the residents were offered a structured timetable that was tailored to the individual based on choice. Residents told the inspector that they were supported to attend college, farm placements, Leigh Court day centre (part of Freeways), working voluntarily at a charity shop and other relevant placements. On the day of the inspection four residents were supported to attend hydrotherapy, another was supported to attend a dentist appointment and another went out for a meal. In addition some of the individuals were attending their day centres. Residents told the inspector that regular trips are planned to places of interest during the weekend. There was a notice board about local events such as Seymour’s Disco and trips to the theatre. A resident stated that they had recently been to the cinema. Staff stated that since the last inspection four residents have commenced a club in the evening where they can join in with a variety of activities and make new friends. Two staff stated that there are activities available most evenings for individuals to join in if they wish. This was further evidenced in care records. The inspector did not have an opportunity to speak with any relatives. However, a returned questionnaire stated that “their relative is very happy living in the home whilst the relationships between residents can be strained this is no different from real life and staff respond with this very well”. Care records included information about friends and family and how to contact them and significant dates like birthdays. Residents stated that they are supported to use the telephone, write letters and make arrangements to visit their relatives. Underhay House and Glenfrome Road another Freeways Home share the same staff team and the registered manager. The manager stated that relationships with the groups have improved and the three residents from Glenfrome Road have agreed to telephone prior to visiting. The staff and the manager, are monitoring the visits. This was in response to a requirement from the inspection in February where it was noted that relationships between one resident from Glenfrome and another from Underhay was strained and an incident occurred where another resident had got hurt during the argument. The Commission for Social Care Inspection has received no further reports. It was evident from observation and discussions with the residents and staff that the daily routine of the home is resident led. Individuals were observed getting up when they wanted, helping themselves to snacks and drinks. It was a busy household with individuals being supported with their chosen activities Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 17 and day-to-day chores. Residents stated that they assist with the cleaning of their bedrooms and preparation of the meals, washing up and general household chores. Residents were observed clearing the table after the lunchtime meal. There was a rota so that the individual knew what they were doing. Residents saw this involvement as positive. Residents stated that the food was good and choice was available to them. This was evident during the lunchtime but this level of choice was not documented on the menu. The home must maintain a record of actual food, which is available to the residents on a daily basis. It was evident that one individual was supported to eat more healthily and was being supported to reduce weight. A dietician had been involved in the plan. The lunchtime meal, which consisted of soup and a roll or tuna salad with pitta bread, was relaxed with staff members joining in. Fruit was readily available in the lounge and the dining area. One resident was supported to make their lunch. Residents confirmed that they could make snacks and drinks throughout the day. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 18 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) 18,19,20,21 Resident’s personal and health care needs were being met. The home was in the process of looking at the wishes of residents in the event of their death. The home operates a robust medication system. EVIDENCE: Residents and staff stated that the day was resident led and individuals chose when to get up and go to bed. This was clearly documented in care records. Information in care records demonstrated that the home was accessing support and guidance from other professionals ensuring a multi-disciplinary approach. This is good practice. The home has a key worker system. The residents and the staff confirmed this. This was described in the statement of purpose and the service user guide. Staff stated that this is covered during induction and discussed and reviewed at supervisions. There were clear records demonstrating that the individuals health care needs were being met including routine visits to the doctors, opticians, dentist and where relevant the chiropodist. There was evidence in the form of letters from Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 19 consultant psychiatrists that they were involved in reviewing the mental health states of individuals. The monthly key worker report included health monitoring and developing an action plan. The manager stated that the psychologist is in the process of developing a health action plan for one individual, involving the individual and the staff team. This is good practice. The home is informing the Commission for Social Care Inspection of events that affect the well being of the residents in respect of regulation 37. The medication system was seen and found to be satisfactory. Including recording, administration and the training of staff. The home has recently changed pharmacy and the manager stated that discussions are taking place regarding some of the issues that the home has had. Namely, if a new stock of medication is not ordered because there is sufficient in the home, the pharmacy does not send a medication recording chart. This will be reviewed at the next inspection, as it was evident that the home was trying to resolve the issue. The home is in the process of seeking the views and where appropriate the views of relatives on the wishes in the event of the individual’s death. This will be followed up at the next inspection. The home has a policy to guide staff through the procedure in the event of a death of a resident. The home has demonstrated that they are meeting the standards relating to personal care and healthcare. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 20 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) 20,21 Residents are confident about raising concerns about the home and that they would be acted upon. Residents are protected by polices and procedures to ensure that they are protected from abuse. This will be enhanced once staff attend the training in August on the protection of vulnerable adults. EVIDENCE: The home has responded to a requirement to ensure that the information in the complaints procedure in relation to individuals to contact is current. The complaints procedure was readily available to individuals living in the home and a copy was on the notice board. Evidence was provided that this was regularly discussed with residents at meetings and in care files residents had signed a record to say that they had been given a copy. This is good practice. The inspector asked several residents their understanding of the complaint procedure. All residents stated that they would discuss with staff, the manager or relatives. The inspector noted that residents’ views are sought at residents meetings and during the monthly care plan reviews, which are completed by the individual’s key worker. The home has a policy on restraint, which clearly states that this is only used as a last result. The manager stated that restraint is not required. The policy is subject to a review. It is recommended that the section on what is required to be documented in the event of staff using restraint be expanded to give staff clear guidance. The manager stated she is part of the working party with the responsibility of reviewing the policy and this will be included. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 21 The home was able to demonstrate compliance to two requirements relating to the training of staff in protection and to ensure the home has a copy of the Bristol City Council’s “No Secrets”. Training for staff has been organised for August 2005. The home is within the timescale for meeting the requirement. The manager stated that she would be delivering this training as she has attended a ‘train the trainer’ course for protection of vulnerable adults. The manager stated she is still waiting for her certificate of attendance. This must be available for the next inspection to demonstrate the manager is competent to provide this training to the team. Three members of staff were asked what was they understanding of abuse and how would they would respond to an allegation. All staff were aware what constitutes abuse and would report this to their line manager or a senior manager. None knew the role of Social Services in the process or when and who should investigate. However, Freeways Policy was clear that this was the managers or a senior managers responsibility. The manager stated that the team are having training in August 2005 and this would be addressed. The home has a whistle blowing policy. All staff and residents were aware of the senior management structure of Freeways and people that they could contact if concerns were raised about the home. A random selection of finances was checked. Monies held in the home accounted with records. There were individual plans relating to support needs of the individuals in respect of their finances. Individuals have their bank accounts and there was a record of all transactions and evidence that personal allowances and benefits were being paid to the individuals. The home operates a safe system for the administration of the finances of the residents. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 22 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) 24,25,26,27,28,29,30 Residents live in a homely environment, which would benefit from a programme of ongoing refurbishment. The home failed to meet requirements from the last inspection relating to the cleaning of the sanitary ware. EVIDENCE: Underhay House comprises of two terraced houses based over three floors and in keeping with the local neighbourhood. The house is situated on a busy main road in a residential suburb. There are good public transport links to the City Centre and surrounding areas. Amenities are close by including a large supermarket and shopping complex. The home has a large secure garden to the rear of the property. There are outstanding requirements relating to the environment namely the replacement of the flooring in the communal areas and the hallway which is worn (and stained in areas of the dining room), the toilets still require a deep clean and there is a need to improve the ventilation in the kitchen. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 23 The manager stated that the carpets will be fitted and the hallway and one bedroom on the ground floor are planned for decoration in September 2005. There was no date for the kitchen ventilation. The manager contacted the provider to see if they could clarify the situation. The provider was required to write to the Commission for Social Care Inspection detailing a plan for the refurbishment of Underhay House. This was not received. The provider agreed to send this to the Commission for Social Care Inspection within 24 hours confirming the dates for the planned works. The Commission for Social Care Inspection received a letter from the provider dated the 25th July 2005, which was received on the 26th July 2005 detailing the refurbishment plan. Decoration of the hallway and new carpets were due to start on the 26th September 2005 and the ventilation of the kitchen on the 21st August 2005. This will be monitored by the Commission for Social Care Inspection. The inspector has arranged to return to ensure that the home deep cleans the sink on the ground floor bedroom and all toilets to remove the staining. The inspector reviewed a random selection of bedrooms. It was noted that these were decorated to a satisfactory standard and contained adequate furnishings. All bedrooms in Underhay House are single occupancy. Residents had personalised their bedrooms with pictures and personal items. The occupant evidently owned each room seen. All bedrooms were lockable. The home has adequate bathrooms to meet the care needs of the individuals. Whilst bathrooms were clean as already mentioned there was deep staining noted in the toilets. The manager stated that the home is restricted on using some of the powerful cleaners that would deal with this and an external cleaning company would be contacted. A follow up visit will be arranged to address this. This was completed on the 26th July 2005 and had been seen to be completed by the Inspector. All other areas of the home were clean and free from odour. Plans were in place to deal with continence issues including reviewing the flooring in one individual’s bedroom. This is good practice. The inspector observed residents relaxing in the conservatory/dining area. Staff stated that the lounge is used more in the evening. All areas were comfortably furnished and homely. The home has sought advice from an occupational therapist in respect of one individual and bathing equipment has been sought. All residents are ambulant. The home has four ground floor bedrooms. There are ramps to the front and rear of the property enabling residents with mobility issues ease of entry. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 24 Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 25 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) 33,34,35,36, Competent staff support residents, however, the home must ensure there is evidence in the home of a thorough recruitment procedure being undertaken. EVIDENCE: There was adequate staffing in the home on the day of the inspection. All staff spoken with had a good understanding of the care needs of residents and their roles as support workers. There was a strong emphasis on community participation, providing a resident led service and encouraging individuals to be as independent as possible. The rota was seen for the last two months. This demonstrated that the home was sufficiently staffed to meet the care needs of the individuals. The manager stated that there should be three staff in the home throughout the day and two staff sleeping in. In addition to the three members of staff there was a fourth member of staff providing opportunities to go out in the community and support with individuals day placements. The rota included an additional member of staff who was funded to support one individual Monday to Thursday on a one to one basis. The staff at Underhay House support the three residents at Glenfrome Road. This was in addition to the above staffing. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 26 The manager, staff and residents spoke positively about the additional staffing and how the home was fully staffed with the last vacancy being filled the week after the inspection. One resident stated that there was still a lack of drivers however from talking with the manager this was being addressed with new staff working in the home. Staff recruitment was discussed. Whilst residents have been involved in drawing up the person specification and have been encouraged to participate in the informal visits of prospective employees they are not involved in the interviewing. The manager stated that the organisation is exploring resident involvement in recruitment and one resident was involved in the employment of staff at the day centre. This will be followed up at the next inspection in relation to increased participation of individuals in the recruitment of staff. Information supporting the recruitment of staff was seen. This was all in place as per the legislation except for proof of identification including a photograph. The manager stated that she had seen this as part of the criminal record bureau check but had not realised that a copy had to be held in the home. The manager stated that this would be addressed. Staff training records and a training plan was seen. This demonstrated that staff are supported to progress through areas of training including a formal induction programme, the learning Disability Award Framework and then on to a National Vocational Award. Evidence was provided that in addition staff attended training relevant to the care needs of the individuals in the home and the statutory health and safety training. There are three staff with an NVQ 3 or 2 in care. The manager stated that once staff complete the Learning Disability Award Framework, a further four staff will be enrolling to complete an NVQ in care. There are three assessors in the home; however, the home uses an external assessor. The home is working towards the government’s strategic plan of 50 of the workforce having an NVQ in care by December 2005. Staff stated that they felt supported in their roles and regular staff meetings and supervisions with the manager were taking place. This was further evidenced via minutes of meetings and supervision records. Staff meeting minutes demonstrated that there was an open culture and staff were encouraged to share their views on a wide range of topics relating to the running of a care home. A completed relative questionnaire stated that the staff were welcoming and responsive to the needs of the individuals. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 27 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) 37,38,39,40,41,42,43 Residents live in a well managed home and a safe environment. However, the home failed to demonstrate how the quality was monitored which included seeking the views of the residents, relatives and significant others. EVIDENCE: Miss Hayward is the registered manager for the home. She has obtained an NVQ 4 in care and management and an NVQ 3 in training and development. She is also an NVQ Assessor. There was evidence that Miss Hayward was keeping up to date and attending periodic training. Staff stated that there was an open door culture in the home both with the manager, the deputy and the team leader. Staff and the residents were aware of the hierarchy within the organisation. It was evident that the provider visited the home on a monthly basis and spoke with the manager, staff and the residents. The Commission for Social Care Inspection receives copies of the monthly provider visits. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 28 The manager stated that presently there is no formal quality assurance tool which seeks the views of the residents, their relatives or significant others. This then should inform the home’s business plan. The manager stated the home is in the process of developing a business plan and a senior manager is assisting in the process. The inspector looks forward to seeing this at the next inspection. The inspector viewed a number of records relating to health and safety. The home has a comprehensive policy on health and safety giving guidance to staff and residents. Fire records were current demonstrating that staff attend periodic training and drills as prescribed by the fire officer and checks were being completed on the fire equipment. The home has a risk assessment on fire, food and activities that staff and residents are involved in. These had been kept under review. There was no up to date gas or electrical equipment certificate. The manager stated that these are held at the main office at Freeways Trust. It is strongly recommended that copies be held in the home. The home has responded to a requirement to ensure that there is a current certificate of public liability insurance. The manager stated that there has been a further issue with the response to general house repairs but this has recently been alleviated as a new person has taken this responsibility on due to a period of absence of the Property Development Manager. The manager stated that works are prioritised and are now being completed within a more realistic timescale. This will be monitored at the next inspection. Budgets were discussed and the manager stated that they have recently been given the staffing budget to enable them to plan more effectively the day-today staffing of the home. The manager stated that the provider regularly discusses the budgets and a plan is devised to ensure that the home remains within budget. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 29 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 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 2 3 2 Standard No 11 12 13 14 15 16 17 3 3 3 3 x x 2 Standard No 31 32 33 34 35 36 Score x 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Underhay House Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 3 3 D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 30 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 1, 33 Regulation 4 Schedule 1 15 (1) Requirement The Statement of Purpose to include minimum staffing. A copy to be sent to the Commission for Social Care Inspection. The home must develop plans of care based on the plan drawn up by the placing authority (Social Worker). All carpets in the hallway and communal areas to be replaced. The hallway to redecorated along with the bedroom on the ground floor. Ventilation must be installed to the kitchen area. Toilets in all areas to be deep cleaned including a sink in Room 5. Staff records to include a photograph and proof of identification as described in Schedule 4.6. For the home to develop a quality assurance tool which seeks the views of residents and where relevant their relatives and a business plan addressing the issues. The home must maintain an accurate record of food that is available to individuals in the Timescale for action 19/8/05 2. 6 19/1/05 3. 4. 5. 6. 7. 28 28 28 27 34 23 (2) (b) 23 (2) (b) 23 (2) (b) 23 (2) (b) 17 (2) Schedule 4.6 35 30/9/05 30/9/05 30/10/05 27/7/05 19/8/05 8. 39 19/1/05 9. 17 Schedule 4.13 (17) (2) 16 (2) 19/8/05 Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 31 (i) home demonstrating that residents have a nutritious and varied diet and are given choice. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 6 42 Good Practice Recommendations Six to twelve monthly care reviews involving the individual and their relatives depending on the wishes of the resident should be in place as per the Statement of Purpose. Copies of the annual electrical equipment checks and the Landlords Gas Certificate to be held in the home. Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 32 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG 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. Extracts may not be used or reproduced without the express permission of CSCI Underhay House D56 D05 S26624 Underhay House V229496 190705 Stage 4.doc Version 1.30 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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