Inspection on 13/09/07 for Manor Park Care Home

This inspection was carried out on 13th September 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 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Manor Park Care Home 30/01/09

Manor Park Care Home 11/03/08

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Victoria Road Care Home 52 Victoria Road Keighley West Yorkshire BD21 1JB Lead Inspector Nadia Jejna Unannounced Inspection 13 September 2007 11:50 th Victoria Road Care Home DS0000069182.V345123.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 Victoria Road Care Home DS0000069182.V345123.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. Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Victoria Road Care Home Address 52 Victoria Road Keighley West Yorkshire BD21 1JB 07786 705 428 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) Mr Olu Femiola Mr Olu Femiola Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (17), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (5) Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC; to service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia - Code MD and Code MD(E) The maximum number of service users who can be accommodated is: 22 This is the first key inspection since the home came under new ownership in March 2007. A random inspection was carried out in June 2007. 2. Date of last inspection Brief Description of the Service: Victoria Road has been registered as a care home since April 1989. In March 2007 it was bought by Mr Femiola who is now the registered provider and manager. Victoria Road care home is in Keighley, close to the town centre and local services such as shops and public houses. It is easily accessible by public transport, being a short walk from the nearest bus stop. The home provides accommodation, personal care and support to people between the ages of 18 and 65 with a history of mental illness. Nursing care is not provided and the home will work with district nurses and community psychiatric nurses if this type of support is needed. The home is detached building that stands in its own grounds. The main building is a Victorian house that has had extensions added to it over the years. Accommodation is provided in mainly single rooms over two floors. The main entrance is up a short flight of steps; people living at the home need to be mobile and able to manager stairs as there are no lifts or facilities for disabled people. There are two lounges, a separate dining room and adequate provision of toilet and bathing facilities. Information about services provided by the home is available in the Service User Guide. Copies can be provided on request. A copy of the most recent inspection was not seen during the visit. Information about the weekly charges for staying at the home were not provided in the AQAA and the acting manager was not able to provide this information when the visits were made to the home in September 2007. Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Three visits were to the home between 13th September and 9th October 2007. The provider did not know that this was going to happen. Feedback was given to the provider at the last visit. The purpose of this visit was to make sure that the home was being managed for the benefit and well being of the people living there and to assess progress made in meeting requirements made at the random inspection in June 2007. During the visit residents and staff were spoken to. Records were looked at such as staff files, complaints and accidents records. Before the visit was planned the provider was asked to carry out a quality assessment of the service stating what they did well, what was in place to prove this, what improvements had been made over the last twelve months and what was planned for the year ahead. This document is called the Annual Quality Assurance Assessment and will be referred to in the report as the AQAA. Other information asked for included what policies and procedures are in place, when they were last reviewed and when maintenance and safety checks were carried out. The AQAA had been returned to CSCI but the information in it was very limited. Comments were made that that the new provider had only owned the home for two months and large sections of the dataset information had not been completed, for example nothing in it about the general occupancy levels, contracting or staff information. Questionnaires were sent to people living in the home, their relatives and healthcare professionals before the visit took place. These people were selected using information provided in the AQAA. When the visit took place surveys had been returned by eight people who live in the home (some had been helped to complete them by the acting manager rather than their relatives, friends or advocates), one relative, one care manager and one healthcare professional. The information from these was used to inform the visit and is referred to throughout the report. What the service does well: The atmosphere in the home was cheerful, welcoming and friendly. It was clear that there are good relationships between staff and people living in the home. People said that they were satisfied with the help and support that the staff gave them. One person said it was good and they could not think of anything they would want to change. Some people are supported and encouraged to maintain social, leisure and educational activities. For example people had been to college to learn computer skills, others went out to social clubs or to play football with their friends. Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The provider bought the home knowing that a lot of work was needed for it to meet National Minimum Standards. Despite this, from the time he took over ownership of the home and when the inspection started six months later, few changes had been made. A random inspection had been carried out in June 2007 following complaints about staffing levels in the home. This found that staff had been employed without proper pre employment checks being carried out, staff had not received training in order to give people their medication and there was little training provided to staff about maintaining the health safety and well being of people living in the home and themselves. Action had not been taken to deal with these issues. The provider was contacted by telephone during this visit and a letter sent telling him that in order to protect people living in the home, staff must not be offered employment until he has received all required pre employment checks. When feedback about this visit was given to the provider he gave reassurances that this information was being requested for all employees at the home. The provider needs to put an action plan together that will identify and target key areas where improvements must be made to make outcomes for people living in the home better and safer. A copy of the plan must be sent to CSCI. Particular attention must be paid to: • Making sure medications are dealt with safely. • Making sure that there are enough staff on duty to meet peoples needs. • Making sure staff have received training so that they can maintain the health, safety and well being of people living in the home and themselves. This must include training about the specialist needs of people living in the home, such as mental health. • Making sure that staff have access to detailed guidance about peoples needs and what they can do to help them. • Making sure that proper records are kept when dealing with concerns/complaints, if holding money in safe keeping for people or if running an amenities/extras fund that people can choose to contribute towards. Requirements and recommendations of good practice have been made and can be found at the end of this report. Another key inspection will be made before the end of March 2008 to look at what progress has been made. Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 7 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. Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can visit the home to find out more about it and ‘test drive’ it so they and be sure it will be suitable for them. This will be better when the home makes sure that people are given all the information they need. EVIDENCE: The provider has produced a Statement of Purpose and Service User Guide. The copy looked at used technical phrases and jargon. The provider was advised that they should be in plain English and in a format that is suitable for people who are likely to use the services provided by the home. The care plan for somebody who had come to live at the home in March 2007 was looked at. It showed that they had come for a visit with their social worker. A copy of their Care programme Approach care plan was at the back of the file, along with a copy of the three way contract between the home, the person and the local authority and information letters from their GP and hospital consultant. The acting manager was in the process of making sure that up to date care needs assessments were in place for all people living in the home. Three way contracts for the previous owner were kept in the home and the provider said that the local authority is issuing new contracts with his details on. Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 10 People living at the home said that they had been helped to choose the home by the local authority. Three out of seven said they had received enough information about the home and the services it provided before they moved in. Information from health professionals survey said that the staff were aware of peoples needs, they were consistent in their approach and had clear boundaries that people understood. Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can make decisions about their daily life and staff will have more knowledge of people’s needs and abilities when the care plans are updated and more detailed. EVIDENCE: The provider has introduced new formats to be used for care plans and risk assessments to replace those used when he took over ownership of the home. The acting manager was working on them and said everybody living in the home would have one. The three care plans looked at were in different stages of completion. The service user assessment and daily care plan is a tick box checklist of a person needs saying yes or no with a small comment box to add any observations. The documents provided an assessment of an individuals needs/abilities/preferences/social interests. This information can be used and expanded into detailed individual care plans providing staff with guidance about how to help and support the individual. Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 12 The risk assessment booklet is a brief grading of risks that includes, self-harm, harm to others, self-neglect and vulnerability. There is room to add detail about a person’s emotional state and their social situation. There are sections for a risk management plan, identified strategies to reduce risk and monitoring arrangements. The risk booklet has the potential to be a good tool to use and pages can be added to it for each identified area of risk. Information from people living in the home said that they made their own decisions about what they wanted to do each day. During the visit people were going about their daily lives and for some this was going out to town to shop, play bingo, visit the pub or for a game of football with friends. The acting manager said that people would tell staff when they were going out and what time they expected to come back. However this was not detailed in the care plans/risk assessments looked at. There were no risk assessments for people who smoked. Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are encouraged and helped to be part of the local community and take part in appropriate leisure activities. EVIDENCE: Staff said that people prefer to have the planned activities in an evening from 7pm onwards. Over the two days of the visit staff were too busy to spend a lot of time with people as they were cooking, cleaning and doing the laundry. People who were not going out either watched TV or listened to music. The provider and acting manager said that they were going to introduce a system of weekly 1 to 1 sessions lasting between 1 and 2 hours per week for people with their allocated key worker. This would be used to talk about any concerns they might have as well as to plan and do activities. People living in the home are helped and supported by staff to learn new skills and take part in appropriate activities. One person regularly attended a local day centre, another had a regular routine of social activities that included Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 14 meals out and going to play bingo. Another had attended college and gained various educational qualifications, they were looking forward to starting a computer course. People can maintain contact with friends and family, including relationships with partners/loved ones. On the second day of the visit the manager had encouraged one person to be more aware of their sexual good health and they had been to see appropriate healthcare professionals for advice. The cook was on holiday and care staff was preparing meals. People said that the food was good. There is a four weekly menu cycle that has been put together by the acting manager and the cook. There is one choice at lunch and teatime but alternatives are always available and staff are aware of peoples likes and dislikes. Special diets can be catered for, for example they are providing meals for somebody of Hindu faith who does not eat beef. They provide halal meat and vegetarian options. People can have snacks and drinks on request. Through the day people came to the kitchen to check what meals were going to be made and to get drinks and snacks. The home has an open visiting policy and people can receive visitors at any reasonable time. If somebody living in the home said they did not want to see a particular person the staff will respect their wishes. This has been done recently where an individual said they did not want to see a particular visitor. The visitor was also seeing other people in the home and agreements were made about the length of the visits and people staying out of each other’s way. The details of this were in and individuals care plan/daily records. The acting manager as advised to keep incident records for recording the details of these types of situations and what actions had been taken to deal with or rectify them. Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s healthcare needs are monitored and appropriate action taken if help and support from healthcare professionals is needed. But there are serious problems with the ways medications are dealt with that place people at risk of mistakes being made. EVIDENCE: Only two staff have completed certificated training in order to administer medication. This is despite the fact that a requirement was made at the random inspection in June 2007. The Medication Administration Record charts (MAR’s) had handwritten entries that had not been dated or countersigned by the person making them. The repeat prescriptions are not seen in the home to be checked and signed, they go straight to the pharmacy from the GP surgery. There were no records of medications received into the home. Staff had used ‘white out’ to cover writing in the controlled drugs record book. One person’s supply of a sedative that is recorded in the controlled drugs book had not been entered as stock received, Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 16 leaving open the opportunity for fraud/theft. The home does not have a recent copy of the British National Formulary to use as medication reference book. One of the people whose care plan was looked at has kept control of their medicines. Each week staff fill a dosette box with his daily/weekly regime of medications using the bottles and boxes sent from the pharmacy. The manager was told to contact the supplying pharmacy and ask that they supply the dosette boxes. The care plan and assessment for self medication did not provide information about how the individual was being supported to self medicate. This is unsafe practice and there is a high risk of errors being made. Staff said they aware of individuals needs and abilities. It was clear that there were good relationships between staff and people living in the home. People living in the home said that staff were ‘nice’ and understanding and that they helped them in ways that suited them. The records seen showed that people’s healthcare needs are monitored and looked after. People can arrange their own GP/dentist/optician visits if they want to or staff will help them. Some people living in the home receive support from community psychiatric nurses and attend out patient’s appointments to see their psychiatrists. District nurses see other people regularly to provide medication support. Two people living in the home are getting older and need help with continence problems. The manager said they had contacted the continence nurse specialist for advice and support. Another person now has restricted mobility and may be at risk of developing pressure sores; the district nurse has seen them and a pressure relieving mattress and cushions have been provided. Another person has fallen six times since the end of July 2007. The acting manager has made sure their doctor saw them and their medication was reviewed. It was recommended that the falls prevention team be contacted as they can supply specialist advice, support and equipment as well as training for staff. As people using the service get older the manager should take into consideration their changing needs and make sure appropriate healthcare assessments are carried out and advice sought from healthcare professionals. Victoria Road Care Home DS0000069182.V345123.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 and 23. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The systems for dealing with complaints are not robust and do not help people to feel confident that their concerns will be listened to and acted upon. EVIDENCE: There is a complaints procedure in place. AQAA said that people are encouraged to come forward with their concerns. Information from people living at the home said that they knew who to speak to if they had concerns and that they knew the procedure to use was displayed in the home. The acting manager has recently dealt with concerns from relatives about financial matters. They did not record it as a complaint and records of conversations about this matter have not been kept. This concern had also been made known to CSCI and the local authority. The local authority will be looking into the issues raised and respond to the complainants. The manager said if people have a complaint they are asked to complete a complaints form. This process might discourage people from raising concerns. Advice was given that staff receiving the information should record what the concerns are and pass it to the manager. Records of meetings and discussions should also be kept. This will provide the home with written information about all concerns that are dealt with and can be used as part of the quality assurance processes to improve services. Some people living in the home have their benefits paid directly into the provider’s bank account and after the homes fees have been paid their Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 18 personal allowances are returned to them. The records looked at were not clear about how much benefit people received, how much was paid to the fees and how much was personal allowance. The books kept to show people had been given their personal allowance was purely a record saying how much had been given to them on a particular day signed by the individual. The home operates a residents/mobility fund that some people contribute to but not all. The money is used to run a mini bus that is used for outings and to take people to hospital/doctors appointments. The previous homeowner was operating this system and the provider continued with when he took over ownership of the home. There was no information about how the fund was to be managed and how people contributing to it were to receive an equitable return from it. There were no agreements in place between the home and the people contributing to it. The records kept showed that it had been used generally in the home and when used for taxis did not say who they were for. The provider was advised that there should be a policy about the fund saying how it will be managed and kept equitable for the people contributing towards it. People contributing towards it should be consulted about how it will be managed and there should be contracts/agreements between the home and people who contribute to it as well as detailed records of monies received and used. The provider said that he would consult with people about the future of this fund and how it will be managed. The care plan for one person showed that when they were admitted to the home they had two bankbooks that were taken into safekeeping. There was no record to show that they had been returned and they were not in the safe. A copy of the local authority adult protection was seen in the staff office. Not all staff have received training about abuse awareness and adult protection. Victoria Road Care Home DS0000069182.V345123.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 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home needs to be redecorated and refurbished so that people will have a safe, comfortable environment to live in. EVIDENCE: The home is ‘tired’ and shabby and is in need of redecoration and refurbishment so that people live in safe, clean, and comfortable home. The provider said that plans were in place to do this over a period of time. He had received quotes to improve the grounds so that people would have nice gardens to use and to build walls that would provide security. When this work had been done the interior of the building would be looked at. The provider said that an action plan would put in place identifying what works need to be done first. This will take into account making sure that all radiators are guarded and any damaged walls are repaired. A new laundry room/area will also be provided as he is aware its current position off the dining room is not good for reducing the risks of cross infection/contamination. He was asked to send a copy of proposed plans for improvements to the home to the CSCI. Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 20 New dining room furniture has been provided and people can now eat their meals from matching tables and chairs that are not plastic. The home was clean and tidy and there were no smells. People said their rooms were kept clean and some kept their own rooms clean. The laundry has recently been reequipped with a new washer that has a sluice cycle on it and a new dryer. Soiled laundry is rinsed in a sink before being laundered because there is no sluice in the home and water soluble red PVC bags have not been provided to place soiled laundry in. Victoria Road Care Home DS0000069182.V345123.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 and 35. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a risk that peoples needs will not be met because there are not enough appropriately trained staff. Recruitment procedures are not thorough and do not protect people living in the home. EVIDENCE: Staff numbers on two days of the visit were low for the number and needs of people living in the home. The acting manager and two care staff were on duty until 4pm and then two care staff to 10pm. A cleaner was working 8 till 1. Care staff were cooking meals because the cook was on annual leave. They were also doing the laundry and did not have much time to be with people living in the home. Staff said normally the cook dealt with breakfast and lunch but they did teatime meals. This means that staff are taken away from their caring and support role to carry out domestic duties. The provider must make sure that there are enough staff on duty to meet the needs and numbers of people living in the home that takes into account their physical, health, social and psychological care needs. Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 22 An immediate requirement was issued to the provider about staff recruitment as three staff files showed that people had been employed before pre employment checks had been carried out. None of the people had enhanced Criminal Records Bureau disclosures or Protection of Vulnerable Adults checks and only one file contained a written reference. The acting manager is aware that there are big gaps in the training provided to staff, especially with regards to the specialist care needs of people living in the home such as mental health, dealing with challenging behaviour and restraint. She is doing an audit of staff training needs so that she knows who needs what training. The provider said that an induction training pack equivalent to the Skills for Care common induction standards has been put together and all staff will do it. He is looking to make two people in the organisation responsible for providing staff training. He was advised that they must have completed appropriate ‘train the trainer’ courses and be deemed as qualified and competent to do so. Because the home provides a service to people with mental health problems staff should be aware of the Mental Health Act 1983 and the Mental Capacity Act 2005 and have access to copies of the Codes of Conduct for these pieces of legislation. Victoria Road Care Home DS0000069182.V345123.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 and 42. People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management arrangements for the home are not clear which means that leadership and direction for staff is not consistent which could impact on the quality of life for people living in the home. EVIDENCE: The management arrangements of the home are not clear. The registered manager/provider is not based in West Yorkshire. He lives in London and owns two other homes, one in Wales and one in Bridlington. During the first two days of the visit the home was being managed and run by an ‘acting manager’ who had been working there since the end of June. The registered manager visits the home weekly to see how things are running and an operations manager spends up to two days a week at the home. They are always available to contact for advice and or support. The provider said he intends to recruit somebody to become the registered manager. He was told to Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 24 write to CSCI with details of how the home is to be managed and what his plans are. Because the provider took on a home with a number of problems and outstanding requirements from previous inspections there is a lot of work that needs to be done. Starting a process of internal audits to identify what needs to be done should be made priority. Quality assurance surveys to find out what the views of people living in the home are will be done around the anniversary of the provider taking over ownership of the home. Regulation 37 notifications have not been sent to CSCI. For example when a person was missing from the home from some time. A copy of guidance available and a from to use were given to the provider. The accident records used are more suited to employees rather than people living in a care home. There was not enough space to record details of the accident and what action had been taken. There was no follow up information on the outcomes of the accident and they did not say when the person was last seen before the accident or by whom. The provider said that all maintenance and safety checks were up to date as these had to be done in order for the sale of the home to go ahead. Victoria Road Care Home DS0000069182.V345123.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 2 3 X 4 3 5 3 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 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 2 34 1 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 1 X 2 X X 2 X Victoria Road Care Home DS0000069182.V345123.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 YA6 Regulation 15 Requirement The provider must make sure that detailed care plans are in place for each person living at the home that will provide staff with guidance about what the persons health, personal, psychological and social care needs are and how to meet them. The provider must make sure that safe systems are in place around ordering, receiving, storing and administering medication for people living in the home. This must include making sure appropriate records are kept and take into account steps to be followed for people who want to look after their own medication. Staff administering and dealing with medications must receive appropriate training. This will make sure that people are helped to receive their medications safely and in accordance with the doctor’s Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 27 Timescale for action 31/01/08 2. YA20 13 (2) 30/11/07 instructions. Timescale 30/07/07 not met. 3. YA22 22 The provider must make sure that systems are in place for recording, investigating and responding to complaints/concerns however they are raised. This will help to reassure people that their concerns will be taken seriously and acted upon. The provider must make sure that all staff receive appropriate training about abuse awareness and adult protection. This will make sure that people living in the home are protected from abuse and that staff will know what to do if they witness or suspect abuse is taking place. 30/11/07 4. YA23 13(6) 30/01/08 5. YA23 17, 20 Schedule 4 (9) In order to protect people who 30/11/07 have asked the provider to look after their finances steps must be taken to make sure that there are systems in place which clearly identify: • How much benefit/money is paid into the providers account and that this account is not used is not used in connection with the carrying on or management of the home. • How much of this is paid as the agreed weekly cost for living at the home. • How much money is left over as the individuals own personal allowance. When and how much money is returned to the individual, which includes their signature and that of the person returning money to DS0000069182.V345123.R01.S.doc Version 5.2 Page 28 Victoria Road Care Home them. If valuables are taken into safekeeping there must be systems in place for recording when they have been received and returned to their owner. 6. YA23 17, 20 Schedule 4 (9) In order to protect people who have agreed to pay money into the mobility/residents fund the provider must make sure that: • People contributing towards it should be consulted and agree about how it will be managed. • A policy will be put in place after the consultation setting out how the fund will be managed, what money can be used for and how it will be made equitable for the people who contribute. • There are contracts/agreements between the home and people who contribute. • Detailed records of monies received and used are kept. In order to make sure that people are living in a clean, safe and comfortable home that is suitable to their needs the provider must make sure that a programme of repairs, redecoration and refurbishment takes place. An action plan detailing what will be done with proposed timescales must be sent to the CSCI by 31/12/07. The provider must make sure that staff receive appropriate training that helps them to maintain the health, safety and DS0000069182.V345123.R01.S.doc 30/11/07 7. YA24 YA30 23 (1)(2) 31/12/07 8. YA32 YA35 18 (1)(c) (2)(b) (4) 31/03/08 Victoria Road Care Home Version 5.2 Page 29 well being of people living in the home and themselves. This must include training about the specialist needs of people especially mental health. Steps must be taken to make sure are aware of their responsibilities under relevant legislation that applies to people living in the home for example the Mental Health Act 1983 and the Mental Capacity Act 2005. New staff must receive induction training that is to Skills for Care common induction standards. The provider must make sure that people who provide training are qualified and competent to do so. Timescale of 30/08/07 was not met. 9. YA33 18 (1)(a) The provider must make sure that there are enough staff on duty at all times to meet the physical, personal, social and psychological care needs of people living in the home. To protect people living in the home the provider must make sure that all required pre employment checks are in place before new staff are brought to work in the home. This was an immediate requirement on 14th September 2007. Evidence to show that the checks have been done and are satisfactory must be kept. 11. YA37 39 (a) (b) Changes in the management team and decisions made by the provider that may impact on the well being of residents must be DS0000069182.V345123.R01.S.doc 31/10/07 10. YA34 19 31/10/07 11/11/07 Victoria Road Care Home Version 5.2 Page 30 notified, and if relevant, agreed with the CSCI. Timescale of 30/07/07 not met. 12. YA42 37 The provider must make sure that any incidents that might affect the well being, safety and security of people living in the home are made known to the CSCI. The provder must produce an action plan showing how requirements will be met within the given timescales and what action will be taken to improve outcomes for people living in the home. 31/10/07 13. YA39 24 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. 1. Refer to Standard YA1 Good Practice Recommendations The provider should make sure that people have access to all the information needed about services provided by the home in the Service User Guide and that it is available in formats that will be easily understood. The provider should make sure that copies of local authority care needs assessments are obtained before people come to live at the home or somebody from the home should carry one out. This will help people to be sure that the home will be able to meet the person’s needs. The provider should make sure that detailed risk assessments are carried out for all areas of activity that might present risk to people living in the home. This should include going out alone and smoking. This will help to promote peoples independence and maintain safety. 2. YA2 3. YA9 Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 31 4. YA14 The provider should make sure that people have access to a range of appropriate leisure activities both in and outside the home. Individual’s needs, abilities and preferences should be taken into account when planning a programme of activities. In order to monitor and maintain the personal and healthcare needs of people as they get older the provider should assess their health care needs at regular intervals and make sure that appropriate health care professionals are consulted for support and advice as needed. In order to reduce the risk of cross infection and contamination the provider should provide water soluble red PVC bags for staff to use when dealing with soiled laundry and when planning the new laundry the provider should consider installing a sluice facility The provider should look at introducing systems of auditing the home that will include obtaining the views of people living there and other stakeholders. The accident records should contain information about when the person was last seen before the accident and by whom, full details of the accident, what action was taken and what the outcome was. This information could be used to prevent future accidents and will be useful as part of the quality assurance/auditing systems. 5. YA21 6. YA30 7. YA39 8. YA42 Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Victoria Road Care Home DS0000069182.V345123.R01.S.doc Version 5.2 Page 33 - 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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