Inspection on 10/05/07 for Vale Road (15a)

This inspection was carried out on 10th May 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 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Vale Road (15a) 05/11/08

Vale Road (15a) 08/05/08

Vale Road (15a) 19/10/05

Vale Road (15a) 27/07/04

Vale Road (15a) 10/02/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Vale Road (15a) 15a Vale Road Ash Vale Nr Aldershot Hants GU12 5HH Lead Inspector Susan McBriarty Unannounced Inspection 10th May 2007 10:00 Vale Road (15a) DS0000013452.V336463.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 Vale Road (15a) DS0000013452.V336463.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. Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Vale Road (15a) Address 15a Vale Road Ash Vale Nr Aldershot Hants GU12 5HH 01252 334880 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) None United Response To be confirmed Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 40-60 YEARS OF AGE 19th October 2005 Date of last inspection Brief Description of the Service: 15a Vale Road is a purpose built bungalow, which is owned by English Churches Housing and managed by United Response. The home is situated in a quiet residential cul de sac in Ash Village. The home is close to local amenities and the railway station, and there are good road links to the nearby towns of Aldershot, Farnborough and Guildford. The home provides accommodation for five residents with learning disabilities, some of whom have physical disabilities. All residents have their own bedrooms and there are two supported bathrooms available. The home has a communal dining room and lounge and there is easy access to a wellmaintained garden. The home has parking for several cars and a minibus. Fee levels for 2006/2007 range from £1.286.65 to £1.300.69 per week. Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and was the first key inspection carried out by the commission. The inspection took place over seven hours (7) hours, commencing at 10:00am and ending at 5pm. Ms Susan McBriarty, Regulation Inspector, carried out the visit. The acting manager was available throughout the inspection. The inspection took into account the records held at the home including resident’s files, staff personnel files, training, medication administration and daily records. The inspector made observations of interactions between staff and residents during the visit and spoke with some of the residents, staff and one relative. Resident feedback was limited due to their communication needs. The pre-inspection questionnaire was not returned to the commission and no completed surveys cards were received from residents, relatives or other professionals. What the service does well: What has improved since the last inspection? What they could do better: A number of requirements and recommendations were made following this visit these include: Arrangements for assessment, care planning and risk assessment required review and change to ensure that residents assessed needs were clearly Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 6 identified, plans were in place to meet those needs and risk assessments completed to identify areas where additional support was needed. It could not be confirmed that all the people who use the service has access to age, peer, religious, social, leisure and culturally appropriate activities. Improvement was needed in planning and recording to ensure residents assessed needs were being met. Some policies and procedures for example safeguarding residents and whistle blowing required review. This would confirm that residents were safeguarded from abuse, neglect and self-harm. Other minor updates needed included the recent changes in the commission. Staffing levels at the home required review to ensure the individual and jointly assessed needs of the people who use the service including activities are met throughout the week. Training opportunities for care staff needed review to enable staff to look at communication methods and appropriate and respectful recording of information. This will ensure that residents are treated with dignity and their privacy and confidentiality is promoted and protected. Further work was needed to ensure a formal, documented annual quality assurance system was in place and that people who use the service and their relatives were made aware of the outcomes. Improvement to the environment was needed to make sure residents live in a homely, comfortable and safe environment. 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. Vale Road (15a) DS0000013452.V336463.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 Vale Road (15a) DS0000013452.V336463.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): Standard 3 was assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvement was needed to make sure the home had the information needed before offering a placement to a prospective resident and how they could be assured that contracts were provided in the best interests of the people who use the service. EVIDENCE: The information kept by the home identified that the people who use the service required a significant amount of support from someone who knew them well to help communicate their views and choices. The views and choices made vary dependent on the individual and they may not have been able to make decisions such as ‘where do I wish to live’. Two files were sampled during the visit. Information about the needs of the people who use the service was available. However it was unclear whether the assessment information provided had been part of the pre-admission assessment or was the care plan. One of the assessments had been electronically signed but neither was dated, nor was it clear who had been involved in the process of gaining the information. The acting manager said that the person most recently admitted to the home did not come with a great deal of information and care staff build their knowledge of the person’s needs over a period of time. A requirement is made to ensure that an agreed, clear process and procedure is in place to ensure that pre-admission information is Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 9 dated, signed including the role of the person carrying out the assessment and that it is clear that it is a pre-admission assessment. This will ensure that the home only accepts individuals whose assessed needs the home is able to meet. Please also see Individual Needs and Choices. A requirement was made during the last visit by the commission on the 19th October 2005 that all the people who use the service had a tenancy agreement or contract held on their file. Both files held unsigned tenancy agreements and one also had a contract with a local authority to provide residential services. The information held by the home does not show whether the residents are able to sign their own contracts or not. This standard was not assessed in full. It is recommended that where residents are not able to sign their agreement to such contracts that this is made clear and that record is signed and dated by a relative, the acting manager or another senior manager to confirm the information. Vale Road (15a) DS0000013452.V336463.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): Standards 6, 7 and 9 were assessed. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Improvement was necessary to make sure that the assessed and changing needs of people who use the service were recorded and documented by the home and that individuals rights including privacy and confidentiality were taken into account. EVIDENCE: Two files were sampled during the visit. As noted under Choice of Home it was unclear if the information was pre-admission information or a care plan. The information set out the needs of the individual but did not make clear how these needs were to be met. The acting manager showed the commission written information that would be provided to agency staff working at the home, this information provided more detail and would assist care staff to know what to do on some occasions. The commission were informed by a member of staff that the style and paperwork completed for care planning had changes since the inspection of the 19th October 2005. Documents showing that reviews took place on a monthly basis were seen by the commission. The documents noted only the month in which the review was Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 11 carried out, they were unsigned and did not show why changes took place including whether any of the goals set had been met. In some instances information that was out of date had been carried forward. A requirement is made that care plans and review documents are developed or further developed to make sure that any person reading the information would be clear about how to provide the care and support needed and what changes had taken place including how and or why. Daily records were kept by the home. The records were not held individually and did not confirm what had happened during the day. Two of the comments used to identify the outcome of the day were ‘well’ and ‘fine’. One comment was brought to the attention of the acting manager as it was considered as inappropriate. The acting manager said that this would be dealt with immediately. The use of one page for the daily record of all the residents did not promote or protect their right to privacy and confidentiality. A recommendation is made for the home to develop and implement an individual approach to record keeping and one that would enable members of staff to record more detail of the day. Please also see the Lifestyle section of this report. A requirement was made during the visit of the 19th October 2005 that the reason why residents do not have the keys to their bedroom be recorded. One of the files sampled held such a record and the requirement was met. However it was noted that almost all the bedroom doors were open during the visit of the 10th May 2007. The acting manager confirmed that one resident does enter the bedrooms of others and remove items of interest to them. The document seen by the commission said that the resident’s bedroom door was locked when the person was out or not using the bedroom was incorrect. A recommendation is made for the home to review why bedroom doors are left open and how resident’s belongings are safeguarded. The acting manager told the commission that one person was no longer allowed to use part of garden following an incident. It was confirmed to the commission that the outcome of the incident leading to a restriction of access had not been recorded or risk assessed. Please also see the Conduct and Management section of this report. Personal care was observed being provided behind closed doors confirming that the members of staff are mindful of the right to privacy. Please also see Conduct and Management of the home regarding risk assessments. Vale Road (15a) DS0000013452.V336463.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): Standards 12, 13, 15, 16 and 17 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The social, leisure and personal preferences of people who use the service were not met and further work was necessary to confirm how the home would meet those needs. The residents were offered a healthy and varied diet. EVIDENCE: As noted in the summary the commission did not receive a completed preinspection questionnaire that would have assisted in confirming the information found or given during the visit. The people who use this service do not access employment or further education due their communication needs. In discussion with the acting manager and members of staff it was confirmed that some of the people who use the service had access to a day centre at various times during the week. The remaining residents did not have any scheduled activities taking place during the day. The daily records did not adequately show what had taken place during the day. Members of staff were Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 13 clear that the daily record page did not offer enough space to show when an activity had taken place so they had not recorded for example when a resident or residents had been taken out. A relative was present during the visit and said she was delighted by the holiday abroad that had been planned and never thought it was going to be an opportunity that would be provided. The commission were also told that the members of staff were very good and approachable. The person spoken with said that they had seen an improvement since their relative had moved into the home. One assessment seen that considered whether the resident would be able to take part in the local election and the outcome of the assessment was clear. During the visit a member of staff was involved in setting up a communication board using photographs and symbols to show what would be happening each day including which members of staff were going to be on duty. In discussion with a member of staff they were aware that it would take some time to learn how to use the board in a way that suited the people who live at the home. Not all members of staff had received training in communication and this training was not documented as being part of their mandatory training. Observations were made by the commission during the visit that indicated that members of staff knew the residents well and spoke to them with respect, took note of the communication taking place and responded appropriately. The lack or documents, records and training in how to communicate with people who do not have speech did not evidence how the home met the age, peer, social, leisure and cultural needs of the residents in a way that would be meaningful to the people who use the service. Some evidence was provided in discussion with the members of staff that activities do take place but not on a regular basis. The requirement and recommendation made under Individual Needs and Choices to develop and implement care plans and a method of recording daily activities must include the issues raised under Lifestyle to ensure that people who use the service receive the opportunities they need to take part in activities, be part of the local community and maintain contacts that are important to them. Please also see the staffing section of this report. A requirement made during the inspection of the 19th October 2005 for a specialist to assess the nutritional needs of the residents had been completed. Members of staff prepare and cook the food provided and also assist with feeding where necessary. The records seen during the visit confirmed that a menu is planned and a record is kept of any change made. The care staff had completed food hygiene training and certificates to confirm completion of the training were seen. Vale Road (15a) DS0000013452.V336463.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): Standards 18, 19 and 20 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further work was needed to make sure that care planning took into account the personal preferences of people who use the service and to further confirm that their health and emotional needs are met. Residents are supported and protected by the home’s policy and procedure for the administration of medication. EVIDENCE: Two resident files were sampled and information was found that confirmed some aspects of the resident’s personal choices and preferences had been recorded. One resident had told the home which staff they preferred. Taking into account the information provided and in discussion with the acting manager this would not be appropriate. However the decision not to agree to this preference and the reason had not been recorded. Another person had a restriction regarding access to the garden; this had not been recorded as a restriction of rights. The requirement made under Individual needs and Choices to develop and implement care plans must include personal preferences, choices and restrictions. Documents and records kept by the home evidenced that the health needs of the residents were met although detailing the health needs in the care plans Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 15 would assist the home in continuing to make sure that residents physical and emotional health needs were met. A policy and procedure was in place for the administration of medication and no errors were found in recording during this visit and as previously required dates for receipt of medication were recorded. Following the inspection of the 19th October 2005 a requirement was made to make sure that any returns to the pharmacist were recorded. A returns record book had been introduced and used for a short time; this had been replaced by the home and the pharmacist now signs the medication administration record confirming returns. Members of staff receive training to administer medication safely and the acting manager said that he also carries out supervision of administration on occasion to ensure practice follows policy. Certificates confirming the training completed were seen by the commission. A recommendation made following the inspection of the 19th October 2005 had received some action and a template had been developed to enable the home to maintain copies of the signatures of those staff trained to administer medication. A further recommendation is made for the template to be implemented and maintained. Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 16 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): Standards 22 and 23 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of the people who use the service and their relatives are listened to and acted upon some work was needed to further confirm that residents are protected from abuse, neglect and self-harm. EVIDENCE: A policy and procedure was in place for dealing with complaints. The management were advised that a minor update was needed to show the changes that had taken place in the commission. The acting manager said that the home had not received any complaints to his knowledge since the last inspection. The commission had received no complaints since the inspection of the 19th October 2005. An easy read version of the complaint policy and procedure was available. One relative spoken with during the visit said that if they had any concerns they felt able to discuss these with the staff, to date they had not had any concerns about the care of their relative. The home’s safeguarding policy was seen. The policy said the local authority should have a multi-agency procedure for safeguarding in place and that senior managers of the organisation would make the decision as to who to inform if an allegation of abuse were made. The acting manager said that the home had a copy of the local authorities 2005 multi-agency procedures for safeguarding adults. It is recommended that the policy be reviewed and revised to confirm that the local authority does have a procedure in place and the procedure all registered services are expected to follow in the event of an Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 17 allegation. No safeguarding referrals had been made either to the home or the commission since the inspection of the 19th October 2005. A whistle blowing policy was in place but did not identify the link between whistle blowing and safeguarding. It was unclear what action would be taken should a whistle blower make an allegation of abuse. A requirement is made for a statement to be added to the whistle blowing policy to make the link to safeguarding clear. The people who use the service would need the support of others to make either a complaint or allegation of abuse. Please also see the staffing section of this report. Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean and hygienic however further work was needed to make sure that people who use the service live in a homely, comfortable and safe environment. EVIDENCE: A tour of the home took place including the bedrooms, communal areas and garden. The bedrooms had been personalised where this was possible. The acting manager said that one person was unable to tolerate having personal or items of interest in the bedroom. Toiletries for use by the residents were held in their bedrooms. The doors to the bedrooms were left open and one person was accessing other people’s bedrooms. It was required that a risk assessment be carried out to ensure the privacy, safety and well being of residents with particular reference to toiletries. The dining room furniture was in the process of being changed around during the visit to take into account personal preferences and the space needed for people who use wheelchairs. Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 19 Requirements regarding the environment had been made following the inspection of the 19th October 2005. These included risk assessments being completed if resident were using the kitchen. During the visit one resident entered the kitchen and another would not, the commission were told that this person never went into the kitchen. Given the issue raised about care planning in this report it is recommended that as part of the development and implementation of care plans that the home review all aspects of their risk assessments to take into account any further identified areas of risk. A requirement made on the 19th October 2005 requires that the identified bath be checked for leaks. During the visit on the 10th May 2007 it was found that both baths had identified leaks that had not been attended to. In one bathroom the leaking water had stained the floor and a small amount of water had pooled on the floor. The pooling water may be a potential hazard to residents and members of staff. In both bathrooms a number of tiles and/or part of the flooring were coming away from the walls and holes had been left on tiles where items had been removed from the wall. The acting manager said that a housing association was responsible for the repairs and decoration of the home and he was uncertain what agreement was in place to state how often decoration took place or how quickly they were to respond to repairs. The door and window surrounds around the home had not been cleaned for some time and needed attention on a regular basis to clean and keep clean. The garden area was viewed by the commission and barbed wire fencing was in place and accessible to the people who use the service. The paving stones that were identified in the inspection report from 19th October 2005 had not been laid flat as required remaining a potential hazard to residents and members of staff. A requirement is made that a review take place of the repairs and cleaning work needed within the home and that action is taken to carry out those repairs cleaning and replacement necessary including those identified in this report. A risk assessment must be carried out of the garden area to ensure that any action identified to ensure the safety and well being of the residents is acted upon including those identified in this report. This will ensure that the people who use the service live in a safe and comfortable environment. Internally the home was clean and hygienic during this visit. Members of the care staff carry out all the cleaning tasks within the home. Please also see the Staffing section of this report. Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34 and 35 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Further work was needed to make sure that staffing levels within the home were able to meet the assessed needs of residents and confirm that residents are protected by the home’s policy and practice regarding recruitment. Residents are supported by appropriately trained staff although review of the programme may assist further staff development. EVIDENCE: Ten care staff were employed by the home not all were full time. The acting manager said three members of staff work between 7am and 2.30pm and two members of staff cover the afternoon and evening shift. One waking and one sleep-in member of staff cover the nights. The acting usually manager worked Monday to Friday and said he was not included as part of the care staff team but assisted as needed. Those on duty during this visit were of mixed gender and all were white. The residents are also of mixed gender and all are white British. Three of the ten staff including the acting manager were qualified to National Vocational Qualification level 3, the acting manager said qualifying training was ongoing for the remaining care staff team. Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 21 In discussion with the acting manager and the staff team it was confirmed that staff tasks include providing personal care, cleaning the home, laundering clothing, preparing and cooking food, acting as escort and providing transport to day centres. The number of staff on duty and the tasks required may have had an impact on the home’s ability to provide stimulation for the residents. As noted previously in this report the home did not have a schedule or programme of activities for people who use the service. As a number of residents did not access external services this had an impact on them and options for stimulation or additional stimulation were limited. A requirement is made that the home review the staffing levels within the home taking into account the tasks care staff are required to complete and the assessed needs of the people who use the service. This will ensure that the residents’ individual and joint needs are met. A policy and procedure was in place for the recruitment of staff. A number of staff files were viewed and confirmed that appropriate recruitment checks had been completed as previously required. The management are advised that where a reference from a named person had not been received and another sought that the reason for this be documented. A requirement was made during the inspection of the 19th October 2005 that application forms include the requirement to provide all employment details including the reason for any gaps. Those application forms seen did not confirm that this change had taken place and a further requirement is made. The acting manager said that training was overseen by the organisations head office including letting the home know when named members of staff needed refresher training. Copies of training certificates were seen including manual handling, equality and diversity, health and safety and first aid. The people who use the service do not have speech and communicate in other ways including taking the arm of staff to lead them where they wish to be or to something they wish to have. The acting manager said that he had attended a one day course to raise his awareness about different forms of communication. A recommendation is made that a review of the residents needs take place to include communication and record keeping in order provide appropriate training to staff and further improve their communication skills including the use of pictures, symbols and photographs. This will assist the staff to meet the communication needs of the residents and ensure appropriate recording. Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvement was needed to ensure residents’ benefit from a well run home that takes into account the views of residents and their relatives’. The health and safety of residents and members of staff was promoted and protected. EVIDENCE: The acting manager said he had been in post for nine months and was now in the process of making application for registration with the commission. The commission were told by the acting manager that he was qualified to National Vocational (NVQ) Level 3 and was working on NVQ level 4 and would be registered to begin the registered managers award within two weeks of this visit. The organisation had a ‘getting it right’ policy and procedure that set out how the organisation expects to find out the quality of the service received. It was Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 23 unclear how the information would be collected and put together so that residents and their relatives would know the outcome of any quality assurance audit. Completed questionnaires sent to relatives were held by the home however overall outcomes and actions from the questionnaires were not available. A requirement made during the inspection of the 19th October 2005 for the home to develop an annual quality assurance questionnaire had been met. Since the last inspection changes have taken place in The Care Homes Regulations 2001 regarding quality assurance. A requirement is made to ensure the home develops and implements a formal, documented annual quality assurance system within the home and outcomes are made known to residents and their relatives. Documented, recorded evidence was seen of weekly checks on the emergency lights and fire alarm tests. Wheelchair maintenance checks were carried out monthly, as were checks on the contents of the first aid boxes. A requirement made during the inspection of the 19th October 2005 for the environmental health office to visit the home was met on the 23rd January 2007. Members of the care staff receive training in health and safety as noted in the staffing section of this report. Accident and incident reports seen had been appropriately completed. Matters raised in other sections of this report such as care planning, risk assessment, reviews and recording indicate that the home does not proactively promote the welfare of the residents. Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 1 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 2 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 X 2 X X 3 X Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 Requirement Timescale for action 27/08/07 2. YA6 15 3. YA6 15(2) A procedure must be in place and followed when carrying out a pre-admission assessment including ensuring the assessment is identified as the assessment, is signed, dated and sets out who was involved in the assessment. This will ensure that individuals needs and aspirations can be met. Care plans must be developed 27/08/07 and implemented for each person using the service and ensure that the documents are identified as the care plan, are dated, signed including where possible by the resident, their relative or representative and the person completing the care plan. The care plan must set out how the home intends to meet the assessed and changing needs of the individual and the residents’ personal preferences. The information documented 27/08/07 and recorded for reviews must be accurate, up to date and set out what has been reviewed and the outcomes. The document should be signed including DS0000013452.V336463.R01.S.doc Version 5.2 Vale Road (15a) Page 26 4. YA7 YA9 YA16 12(2)(4) 13(4) 5. YA13 YA14 YA15 16(m) 6. YA16 12(4) 7. YA23 13(6) where possible by the resident, their relative or representative and the person carrying out the review. This will ensure that the home is able to continue to meet the assessed and changing needs of people who use the service. Risk assessments must be reviewed and/or introduced to ensure they include all aspects of daily living including where restrictions of choice, independence, access, open bedroom doors and access to toiletries have been introduced. This will ensure that the rights and independence of residents have been taken into account. The person completing them must date and sign the risk assessment. The provision of regular and age, peer, gender, culturally appropriate activities must be reviewed to ensure that all residents are provided with the support necessary to be part of the local community, engage in leisure and social activities and maintain appropriate relationships including with family members. Any record kept by the home including daily records must be individually completed in order to maintain the confidentiality and privacy of the people who use the service. The policy and procedure for safeguarding required review to ensure that it supported the local authority multi-agency guidelines for safeguarding adults including making clear the responsibility for making referrals. Related policies including whistle blowing also DS0000013452.V336463.R01.S.doc 27/08/07 29/06/07 29/06/07 31/08/07 Vale Road (15a) Version 5.2 Page 27 7. YA23 required review to include a statement that identifies links between whistle blowing and allegations of abuse. This will confirm that people who use the service are protected from abuse. 23(2)(b)(d) A review of the environment (o) including those matters identified in this report internally and externally for example, 1. Leaking baths 2. Stained bathroom floor 3. Loose tiling 4. Unclean exterior door and window surrounds and 5. Barbed wire fencing; must take place and repairs, replacement and any action required identified and carried out including the flagstones identified in the last inspection report. This will ensure that the health and safety needs of residents and members of staff are identified and that the home is made safe and comfortable for the people who live there. 29/06/07 8. YA32 9. YA33 Timescale regarding the flagstones from the inspection of the 19th October 2005 not met. 12(4) Any record completed by a 29/06/07 member of staff including the daily record must be completed using language that respects the confidentiality, privacy and dignity of the people who use the home. 18(1)(a)(b) A review of the staffing levels 27/08/07 within the home must be carried out. This will ensure that the home is able to meet the assessed needs of the people who use the service including DS0000013452.V336463.R01.S.doc Version 5.2 Page 28 Vale Road (15a) 10. YA34 19, Schedule 2 11. YA39 24 access to suitable, regular activities. The application forms must be updated to ensure prospective members of staff are asked to provide information about all their previous employment including any gaps in service and the reason. A formal system for a quality assurance audit that takes into account the views of the people who use the service and their representatives and provides a report setting out what action is needed to improve the quality and delivery of the service must be developed and implemented. This will ensure that the views of the residents and their representatives underpin the running of the home. 31/08/07 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA5 Good Practice Recommendations Where people who use the service are unable to sign and agree their tenancy or contract agreements it would be good practice to identify this and record the matter in the tenancy/contract section of individual resident files. It is recommended that an activity schedule be developed and implemented within the home to ensure that people who use the service can be assisted and supported to know what is happening during the day. It is recommended that the template developed to identify members of staff able to administer medication is implemented and maintained in full. It is recommended that members of staff be provided with training regarding communication and recording. This will ensure that the home is able to proactively promote the rights and dignity of the people who use the service. DS0000013452.V336463.R01.S.doc Version 5.2 Page 29 2. YA13 YA14 3. 4. YA20 YA35 Vale Road (15a) Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Vale Road (15a) DS0000013452.V336463.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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