Inspection on 03/08/07 for Underhay House

This inspection was carried out on 3rd August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Underhay House 16/07/08

Underhay House 13/09/06

Underhay House 26/01/06

Underhay House 19/07/05

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 Nicky Grayburn Key Unannounced Inspection 17th July 2007 09:30 DS0000026624.V337571.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 DS0000026624.V337571.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. DS0000026624.V337571.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Underhay House Address 639-641 Muller Road Eastville Bristol BS5 6XS 0117 9519094 01275 372151 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) Freeways Trust Ltd Miss Claire Anne Hayward Care Home 12 Category(ies) of Learning disability (11), Mental disorder, registration, with number excluding learning disability or dementia (1) of places DS0000026624.V337571.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 2006 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 Mrs Debbie Carpenter. The accommodation comprises of two 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. 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. The range of fees is from £502.17 to £680.42. Items such as hairdressing, activities, clothing and personal items are not included in this fee. DS0000026624.V337571.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was Underhay’s key inspection and was carried out over two days. It was unannounced. The inspector met with many of the residents and staff, including the new Manager. There were 8 requirements and 2 recommendations to follow up from the previous visit. Prior to the inspection, previous records and reports held at the Commission for Social Care Inspection were read. During the first part of inspection (2 hours), the inspector met with the manager and some of the residents and gave the manager 11 surveys for the residents to complete over the weekend. The second part of the inspection (5 hours) took place during the late afternoon and evening. The inspector met with nearly all the residents, staff and the manager. The inspector looked at key documents; talked with and observed residents, staff and the Manager on a one-to-one basis; and looked around most of the property with residents or staff. 6 residents completed the surveys over the weekend. Relatives’ surveys had also been sent to the home to distribute. 2 of these surveys were returned. All of the surveys have been analysed and form part of this report. Three residents were case tracked and the inspector spot-checked other residents’ records. Verbal feedback was given at the end of the inspection to the manager. The previous manager Claire Hayward was transferred to another of Freeways homes in January 2007 due to re-structuring within the organisation. Another manager was placed there but left in May. For 3 months there was no formal manager. Mrs Debbie Carpenter became Manager in July. What the service does well: Many of the residents told the inspector that they “love living here”; “I love it here” and do not want to move. An added comment from a relative’s survey was “it always seems a happy house, very friendly.” Staff seemed knowledgeable about residents’ care needs. DS0000026624.V337571.R01.S.doc Version 5.2 Page 6 Residents have lifestyles which they enjoy and have chosen. Most residents participate in varied activities and attend day centres and colleges, and some have jobs. The new manager is competent and will bring the home up to a good standard again. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000026624.V337571.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000026624.V337571.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5 People who use the service experience adequate quality outcomes in this area. The statement of purpose does not reflect current practices, therefore would not enable residents to make an informed decision about whether to move into the home. Residents’ needs are assessed prior to moving in but the home has not developed how the home will meet them. Residents are generally offered to look around the home and ‘test drive’ it prior to moving in. Residents do not have up-to-date contracts ensuring that they are know what to expect from the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s Statement of Purpose is in need of updating to reflect current practices and what the home provides. It also needs to be in a format which residents can understand. The manager is starting to separate the two registered homes’ paperwork (Glenfrome and Underhay) in order to ensure that the resident’s needs are fully met. From the care files looked at, residents had assessments carried out by their Social Worker prior to moving in to ensure that the home can meet their needs. As evidenced in later parts of this report, it was discussed with the DS0000026624.V337571.R01.S.doc Version 5.2 Page 9 manager how some residents’ needs are not being met as per their preassessment plans and/or current needs. Requirements have been made regarding this. Despite it having been a long process, one resident is soon to be leaving Underhay as their needs will be better met at another home. There is one new resident living at Underhay. However, no specific care plan or assessments had been written by the home to indicate how the identified needs will be met. Staff told the inspector that placements often quickly happen and there is not enough time to record information. 5 out of 6 residents stated on their survey that they were asked whether they would like to move into the home and all 6 stated that they received enough information about the home to make an informed decision. Added comments included “I choose to try it”; “I looked around this one”, and “I was not asked, I had to take what was available”. Some residents told the inspector about when they came to look at the home. This involved over-night stays and meeting the other residents. Some files contained copies of the service user guide and induction packs, which stated that copies had been given to the resident. Some residents had ‘resident agreements’ within their files. However, these were dated from 2002. Newer residents did not have any contractual agreement in place. The manager found copies of placement costings, but they were out-of-date. The manager will be updating these with other documentation. This will be followed up at the next inspection. DS0000026624.V337571.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ changing needs are not always assessed and reflected in their plans. Residents make decisions about their lives and are involved in some aspects of the home. Not all residents are supported to take risks within their lives. EVIDENCE: An added comment from a relative survey was that the home “helps *** to live as he chooses, to have a lie in, be flexible about meals, they help *** to make good choices.” During the inspection, the manager and the inspector found little evidence to show that residents had care plans in place to meet their current care needs. Through talking with staff, it was clear that some residents’ pre-assessed needs have changed, yet, not documented. One resident showed the inspector their pathway plan in their bedroom which showed their goals and aspirations. The inspector did not see any other record of this. Some residents have DS0000026624.V337571.R01.S.doc Version 5.2 Page 11 received reviews of their needs with their social workers and other supporters such as family members have been involved. Some residents were not aware of their care plan, whereas some were. Care plans, once established, must be reviewed regularly to make sure that all staff are aware of changes. Each resident has a key worker. Residents and relatives’ surveys informed the inspector that there have been many changes in the past few months. It was clear that key workers are supposed to write up monthly reports with the resident about that past month. These are not regular and for one resident, the last report dated February 2006. Many last reports were from April 2007. The manager told the inspector that once an example file has been completed, key workers will be designated to involve the resident and complete the full set of records. All 6 residents who completed the surveys said that they could do what they wished during the day, evenings and at weekends. It was observed during the inspection that residents could make decisions about their lives. 1 resident continues to be an active member of a local advocacy group. Residents can attend regular meetings within the house to discuss issues. The inspector read the minutes from the past few meetings and it appears that most residents feel able to voice their opinion. Some residents have some risk assessments in place to make sure that they are safe and enabled to take risks within their lives. Many of these are old and need updating. For some residents, there is no documentation to evidence this at all. A requirement was made regarding this at the previous inspection and it will remain. The manager is, again, aware of this and the staff team will be carrying out this task. DS0000026624.V337571.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Most residents have a lifestyle which they enjoy and have chosen for themselves. Residents are able to follow a daily routine which suits them. Residents are offered a varied and healthy diet. EVIDENCE: Residents told the inspector about their allocated days when they carry out life skills tasks such as their laundry and household chores. This is sporadically recorded. Residents wrote on their surveys and told the inspector about their visits to a local church. Residents told the inspector about college courses they have done and those they would like to do. Many of the residents also attend the organisation’s day centre ‘Leigh Court’. Some residents told the inspector that they mainly enjoy this and look forward to, but some have stopped going due to various reasons. There is a communal computer for residents to use, and it was observed that DS0000026624.V337571.R01.S.doc Version 5.2 Page 13 some use it to play educational games. Residents are also able to attend a regular social club. From speaking to residents, some do not go out much and are not sure what they would like to achieve. A drawn up care plan with the resident will help some to establish what they would like to do. It was observed that residents go out and about in the community and access events within the city. Some of the residents had gone to Alton Towers over the weekend which they enjoyed. Holidays are planned within the UK and abroad. Residents told the inspector about where they have been, where they are going, and where they would like to go next. Most residents have family members and friends, and these relationships are supported by staff, for example making phone calls and arranging to meet up. Some residents told the inspector that they would like more support to make and keep friends within and outside of the organisation. It observed how staff talk with residents with respect, and residents are permitted to access all the shared areas within the house and can choose whether they be alone or with each other. The menu for the week’s meals was displayed in the kitchen, which showed a varied diet. Residents told the inspector that “the food is fantastic”, others said that “its okay but everyone’s on diets”. On the menu, it was written who had chosen that meal, and the manager confirmed that this is rotated. Some residents enjoy helping and preparing the meals. The manager must remind staff to record what each resident has eaten and what alternatives are offered. DS0000026624.V337571.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. It is not clear that residents receive personal care in a way they wish. Residents’ health needs are generally met. The medication procedure protects residents. EVIDENCE: The majority of the residents in Underhay have a learning difficulty. Some have sensory difficulties as well. Residents also have other needs regarding physical mobility and mental health issues. There are no care plans for some residents who need support with their personal hygiene. There are no care plans for those who have continence difficulties. Some residents prefer the same sexed member of staff to assist them to carrying out certain tasks. This must be included in their care plan. A requirement has been made regarding this. It was observed and residents told the inspector that they could get up and go to bed when they wish. DS0000026624.V337571.R01.S.doc Version 5.2 Page 15 It was observed that residents dress in clothes that reflect their personality. Issues were brought to the attention of the inspector regarding laundry. As stated earlier, residents are supported with their life skills and residents are reminded about the process of this. Both relatives’ surveys stated that staff always respect the individual’s privacy and dignity. This was also observed during the inspection. Templates for residents’ Health Action Plans are in place but are currently blank. The manager is aware of this and will endeavour to ensure that these are completed along with the care plans and risk assessments. This will be followed up at the next inspection. There are records of when residents have attended appointments with external health professionals such as the dentist, optician and local General Practitioner. However, for one resident, there are no details at all. The manager assured the inspector that this record will be set up along side the other necessary records. From records read, specialist health professionals are sought when necessary. There was also some discrepancy between what was on the pre-assessed needs and actual practice regarding testing blood sugar levels for those with diabetes. The care plan also states that foods eaten must also be recorded. The correct practice for this must be sought to ensure that residents remain safe. An immediate requirement was not made as the manager assured that this would be sorted straight away. It is required for the manager must send a copy of the revised care plan to the Commission for Social Care Inspection within 28 days of receipt of this report. A recent finding of a medical condition was dealt with effectively and all residents are now protected. However, the manager must ensure that all staff are also protected. A senior member of staff is responsible for the medication. The cupboard is locked at all times and is kept in the dining area. Not all residents are prescribed medication. No residents look after their own medication. There are no controlled drugs kept on the premises. There have were a number of medication issues last year and the Commission for Social Care Inspection was duly informed of these. The member of staff told the inspector that they have nearly finished the new profiles for the file to ensure that all staff are aware of the side effects of and reasons for the drugs. A requirement from the previous inspection was a record to be kept of all residents consent to the administration of medication. There are letters in some resident’s files confirming their consent through the Community Learning Difficulties Team. The manager must ensure that this requirement is fully met. One resident’s DS0000026624.V337571.R01.S.doc Version 5.2 Page 16 medication dosages did not correspond with a letter from their Doctor. The staff member will be following this up. The home also holds some homely remedies such as paracetamol for residents. Freeways provide comprehensive training regarding the administration of medication and then the staff member completes a series of competency tests. Staff will be observed until the manager is certain that they are competent. Some residents require a particular drug when they suffer from an epileptic seizure. There have been some issues regarding this. The staff team are receiving training next week regarding the administration of it. The external professionals involved are fully aware and the staff team are doing what they can to resolve this. Clarity on this issue is needed to fully ensure that the resident is safe. The inspector is contacting the Commission for Social Care Inspection’s Pharmacist to gain further advice on this matter. DS0000026624.V337571.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People who use the service experience adequate quality outcomes in this area. Residents feel comfortable with raising concerns with staff. However, these are not effectively acted upon or recorded. Residents feel safe and are protected in their home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection, it was observed how residents approached staff, and the inspector, with concerns and issues they wanted to talk about. The surveys which some residents completed shows that all 6 residents know who to speak to if they are unhappy, such as the manager; staff; family members, or their social worker. There was a varied response in the surveys asking if residents knew how to make a complaint. 3 residents stated that the staff members always listen and act on what they say, 2 residents said sometimes and 1 resident did not answer that question. It was noted in a residents meeting in April that residents were reminded of how to make a complaint. In the meeting in May, some residents raised complaints. However, these were not recorded. The complaints folder held loose pieces of paper with no actions or outcomes for the resident. The last recorded complaint was from 2004. However, it was felt that the most recent complaints log has gone astray. The manager is setting up a new binded book for complaints to be recorded. The relatives’ surveys stated that complaints were not always responded to or sorted out. It is hoped that with a new permanent manager, this will improve. This area will be followed up at the next inspection. DS0000026624.V337571.R01.S.doc Version 5.2 Page 18 The previous inspection report states that all the staff have received training in Protection of Vulnerable Adults either through the local authority or by the previous manager Ms Hayward. However, there was no evidence in the staff’s files to evidence this. Whilst talking with residents, all stated that they felt safe within the home. Freeways organisation provides this training during the staff’s induction period and through the initial training course. Then there are annual refresher courses for staff to attend. This must be evidenced. Residents’ personal monies were not inspected on this visit. However, they are not kept safe. The manager is buying a new safe for this purpose. A previously made requirement was for residents’ inventories to be updated. None were seen in the files or located during the inspection. The manager has since informed the inspector that these were completed in February 2007 for 6 of the residents. One list in note form was seen in the office. The requirement remains. DS0000026624.V337571.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 29, 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable home. Residents have individualised and personalised bedrooms suiting their needs. A maintenance programme would ensure that the home maintains a homely and safe environment. Bathing facilities need to be improved for some residents. EVIDENCE: The inspector looked around the home with staff and residents during both visits. Underhay house is a combination of an end-of-terraced house and the adjoining one. A monthly report from the organisation stated that the front of the house has been re-painted and is in keeping of the surrounding area. There is a good sized garden which the residents said they like with seating and plants. The manager has already informed her line manager about areas that need attention. A requirement had been made regarding the ventilation in the kitchen, which has been met by installing a fan system, but people are not sure as to how to use it. Due to the summer weather it has not been DS0000026624.V337571.R01.S.doc Version 5.2 Page 20 particularly necessary to use the system but staff should know how to use it when cooking is being done due to the heat that is produced. The other requirement was to improve the lighting in the conservatory especially for those with sensory difficulties. Staff confirmed that the lighting has been changed and is much better at night and during the darker months. There is a large light lounge that the residents use to relax in. There is also a large conservatory dining area that is used more as the hub of the house. Some residents proudly showed the inspector their bedrooms, which were personalised and fairly clean. Residents told the inspector that they help to clean their rooms. Most of the bathrooms were looked at. There are enough bathrooms for the number of people sharing in the home. The upstairs bathroom has brown/black areas on a wall and there is also a large crack by the doorframe. Residents told the inspector how they would like to re-decorate it and the surrounding landing area to make it nicer. The flooring in the first floor bathroom does not meet the bath’s edge and has become blackened and is unhygienic. The tiling has recently been re-done but the appliances have not yet been re-fitted. The ground floor bathroom has the only shower in the house. The radiator has a lot of rust on the corner and the bath’s panel is falling off. Two residents who use this bathroom have mobility difficulties and need support when washing. Staff told the inspector that there have been incidents of residents slipping when climbing in and out of the bath. There is a small plastic step and a grab rail but this is not sufficient. It is required for the home to reassess the residents’ needs and provide a safe method of washing, such as a walk-in shower. The home now has a cleaner who works 20 hours a week. The residents’ surveys showed a mixed response in answering whether their home is fresh and clean. 2 residents said always, 2 said sometimes and 1 said never (1 resident did not answer). Added comments included “I need help to clean my room”, and “it is very dirty and smells, the bathrooms and sinks should be cleaned every day”. A recent residents’ meeting addressed the household chores undertaken by residents. This is now on a monthly cycle so residents are not ‘stuck’ with the same chore all the time. There are areas within the home which need sorting to avoid accidents, such as, the vacuum cleaner under by stairs. Head office provides the home with a 3-yearly maintenance programme to ensure that all shared areas are re-decorated within this time frame. Other repairs and replacements are authorised from head office as and when necessary. DS0000026624.V337571.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Some residents are supported by a competent staff team, however, some residents’ needs are not being met due to a lack of training. The home’s recruitment practices need to fully follow the home’s policy to protect the residents. An improved supervised staff team will support residents. EVIDENCE: There is a staff team of 12, including a regular bank staff member who covers shifts if necessary. There is also a deputy manager. The majority of staff are part time and no recruitment agency staff are used. On average there are 3 staff on duty at a time, however, this includes staff for residents living in Glenfrome. There is also a sleep in staff member. The manager is in the process of developing the rota to ensure that it is clearer and that staffing levels match the residents’ needs. It was evident during the inspection that residents were able to spend one-to-one time with staff and staff were available to do this. However, some residents told the inspector that staff were often very busy and sometimes could not go out due to there not being enough staff. DS0000026624.V337571.R01.S.doc Version 5.2 Page 22 There was little evidence that staff meetings occur regularly. The manager intends to re-start these meetings on a regular basis. 5 of the 6 residents stated on their surveys that staff ‘always’ treat them well. 1 stated ‘never’. The inspector spoke with this resident during the inspection. Relatives surveys had a variety of comments regarding the staffing such as “on the whole, some extremely caring staff members”; “some are very good, some are bad”; “staffing has been a problem”; “staffing levels curtails activities”. The inspector spoke with the majority of the staff members on duty during the inspection. All appeared competent in their job and answered in detail to questions around the resident’s care needs. The inspector viewed 5 staff member’s personnel files. 3 were well organised and hold the necessary information in line with the home’s recruitment policy such as a completed application form; evidence that a Criminal Records Bureau check had been carried out, and two satisfactory references. However, 2 newer members of staff’s files did not hold the necessary documentation, or even have a file. There was some evidence of statutory training and completion of qualifications such as the Learning Difficulties Assessment Framework and National Vocational Qualification in care. However, 2 staff members are in need of statutory training and/or refresher courses such as food hygiene; fire safety, and manual handling. The manager is aware of this and will be identifying the training needs for the whole team. Head office is centralising this process, with managers, to monitor and ensure that staff are fully trained. It was extremely evident during the inspection that staff are in need of training in British Sign Language in order to effectively communicate with some residents who have sensory difficulties. It was observed how some staff can spell out the alphabet and communicate on a basic level, and those staff who have worked at the home for a long period of time have developed a level of understanding. The previous report stated that a course had been booked but was cancelled. It is required for staff to receive this training. Supervision sessions over the past year have been sporadic. 2 staff have received supervision recently, but some have not had this support since August 2006; or there was no notes on file at all. The manager and staff members told the inspector about various issues within the staff team which have arisen from the changes in recent months. The manager has already started with the supervision sessions and there is a list on the board with all staff booked in. It is hoped that the staff will feel more stable and supported again since the appointment of the new manager and issues can be dealt with effectively. DS0000026624.V337571.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents now have a permanent manager, which will hopefully ensure that the home is better run. The home needs to ensure that resident’s views underpin the ethos and development of the home. Residents are safe within the home. EVIDENCE: As stated earlier, Mrs Debbie Carpenter is now the new permanent manager at Underhay. The home has undergone a lot of change since January 2007 and staff and residents are hoping that it will remain stable now. Mrs Carpenter has worked for Freeways for a number of years and has been transferred from another of Freeways homes where she was the manager for 5 years. Mrs Carpenter worked at Underhay in 2002 and knows many of the residents. DS0000026624.V337571.R01.S.doc Version 5.2 Page 24 Since starting at the home, Mrs Carpenter feels that she has received a lot of support from senior management. It was discussed with Mrs Carpenter that she must apply for Registration with the Commission for Social Care Inspection. Much paperwork and documentation regarding the residents and the home could not be located during the inspection. Mrs Carpenter is in the process of organising it all and is well aware of the work that needs to be done. A relative’s survey added that there are many issues within the home but felt that it was possibly due to the lack of management over the past few months. It was evident that over the past few months, record keeping has not been maintained. Despite staff being aware of residents’ needs, the records did not reflect this. The Annual Quality Assurance Assessment was not returned to the Commission for Social Care Inspection. It is a legal requirement for this document to be completed. Other members of staff and management are permitted to complete this if there is no registered manager at the home. It must be returned next time or further action will be considered. The home’s quality assurance system has been set up and is now due to be implemented. There are ‘Service User Inclusion and Satisfaction questionnaires’ to be given to the residents. One had been completed in June 07. The home receives monthly visits from the area manager who carries out an audit, then writes a report along with the Personnel manager and the Financial Director. This is duly sent to the inspector. The manager is aware that the quality assurance system is an area for development in the near future. A member of senior care staff is responsible for the health and safety of the home. The fire folder was read. Head office provides each of the homes with a list of dates and copies of the certificates when the statutory maintenance contractors have inspected and checked the home, such as electrical installations and the fire safety system. The only item that was out-of-date was the gas landlord safety certificate. The manager must confirm in writing in response to this report that this has been carried out as normal. There was no evidence of fire drills being carried out. The previous requirement will remain. DS0000026624.V337571.R01.S.doc Version 5.2 Page 25 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 2 2 1 3 2 4 3 5 2 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 3 27 2 28 3 29 1 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 2 1 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 2 X 2 X 1 3 X DS0000026624.V337571.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 4 Schedule 1 Requirement The manager to update the home’s Statement of Purpose in line with Schedule 1 and to reflect current practices and services within the home. a) Care plans to be written and/or revised. b) An identified resident’s care plan is to be sent within 28 days of the receipt of this report. (outstanding requirement, previous timescale 31/01/07) Timescale for action 31/10/07 2. YA6 14(2) 15 31/10/07 3. YA9 12(1)(a) Update risk assessments. 31/10/07 4. YA10 13(2) Keep a record of all residents consent to the administration of medication. (outstanding requirement, previous timescale 30/11/06) 30/11/07 5. YA18 13(5) Plans to state how residents wish 31/10/07 to be supported with their personal and health care needs. Risk assessments must be carried out regarding specific health problems. Repairs and redecoration within DS0000026624.V337571.R01.S.doc 6. YA19 13(3) 30/10/07 7. YA24 23(2b) 30/11/07 Page 27 Version 5.2 the 3 identified bathrooms to be undertaken. 8. YA29 23(2n) The home must provide appropriate and safe bathroom facilities for residents. To ensure that there are staff on duty at all times who can communicate effectively with the residents. Staff need to undertake training in communication skills, which are relevant to the residents’ needs. Ensure all staff are involved in regular fire drills. 30/11/07 9. YA33 18(1a) 31/01/08 10. YA42 23(4)(c) 30/09/07 (outstanding requirement, previous timescale 03/10/06) 11. YA41 Sch 3 (outstanding requirement, previous timescale 31/12/06) Update residents inventories 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000026624.V337571.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000026624.V337571.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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