Inspection on 20/08/09 for Walc House

This inspection was carried out on 20th August 2009.

CQC found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Walc House 23/06/08

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Walc House 8 Argyle Road Swanage Dorset BH19 1HZ Lead Inspector Jo Johnson Key Unannounced Inspection 20 & 21st August 2009 10:00 th Walc House DS0000070429.V377239.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Walc House DS0000070429.V377239.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Walc House DS0000070429.V377239.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Walc House Address 8 Argyle Road Swanage Dorset BH19 1HZ 01929 422200 01929 422200 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.walc.uk.com Walc Ltd Ms Deborah Kate Tutin Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Walc House DS0000070429.V377239.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 either gender whose primary needs on admission to the home are within the following category: 2. Learning disability (Code LD) The maximum number of service users who can be accommodated is 3. Date of last inspection 23rd June 2008 Brief Description of the Service: Walc House is owned by Walc Ltd. The abbreviation ‘Walc’ stands for ‘Wood Autistic Living and Care’. It is currently the only registered care service owned by the company. The service was registered with the Commission in January 2008 to provide accommodation and personal care for up to three people with learning disabilities. The service aims to provide a care service specifically tailored to meet the needs of adults with autistic spectrum disorders. The home is a large terraced property situated along a residential street approximately half-a-mile from the centre of Swanage. Accommodation is provided in three single bedrooms on the first and second floors of the home, all of which have en-suite facilities. A communal kitchen and communal lounge are situated on the lower ground and ground floors. There is a landscaped garden to the rear of the property which is accessible from the kitchen. Local amenities are within close reach. Car parking is available along the street. The home is staffed 24 hours a day with waking night staff. On 21st August 2009 the range of fees was £2100.33 to £3869.56 per week. This is inclusive of sensory programmes, basic toiletries, use of laundry facilities and all activities as outlined in the home’s Statement of Purpose. The Guide states that any additional costs will be calculated in accordance with the company’s pricing policy. Walc House DS0000070429.V377239.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience Adequate quality outcomes. The focus of inspections undertaken by us is upon outcomes for people who live at the home and their views of the service provided. This process considers the homes capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. This report uses information and evidence gathered during the key inspection process, which involves a visit to the home and looking at a range of information. This includes the service history for the home and inspection activity, notifications made by the home, information shared from other agencies and the general public and a number of case files. The acting manager supplied the commission with an AQAA (Annual Quality Assurance Assessment). Information from this has been used to make judgements about the service, and have been included in this report. Surveys were not sent out to people living at the home as the people have complex communication needs and they are not accessible to them. This inspection visit was unannounced (we did not let the home know that we were coming) and took place on 20th August between 10:00 am and 11:30am and on 21st August between 10:00 am and 3:00 pm. The acting manager was not on duty on the first day of inspection so we arranged to return the following day. The inspection involved: • Observations of, Makaton signing and talking with the people who live at the home and the support workers and manager on duty at the time. • Observation of working practices and of the interaction between individuals and staff. • Two people were identified for close examination by reading their, care plan, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’, where evidence is matched to outcomes for people. • A tour of the environment was undertaken, and home records were sampled, including staff training and recruitment, health and safety, and staff rotas. This inspection was carried out by one inspector and one pharmacist inspector but throughout the report the term we is used, to show that the report is the view of the Care Quality Commission. Walc House DS0000070429.V377239.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: There needs to be ‘as needed’ medication plans in place, so that staff know when to safely give people their medication. There must be a clear adult protection and safeguarding procedure that is easy for staff to follow. This is so they know how and to whom they can report any allegations of abuse. Walc House DS0000070429.V377239.R01.S.doc Version 5.2 Page 7 Incidents where people are physically aggressive and harm other people at the home must be reported to the commission and to the local authority under adult protection safeguarding procedures. This is to make sure that any allegations are appropriately investigated and actions taken to safeguard the people living at the home. A fire risk assessment must be place that details the actions to be taken. This is to ensure the fire safety at the home. Good practice recommendations have also been made. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Walc House DS0000070429.V377239.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 Walc House DS0000070429.V377239.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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’s care and support needs are comprehensively assessed to ensure that individual needs can be met. EVIDENCE: The home is now fully occupied, two people have moved in since the last inspection. We looked at the assessment and care records for the last person to move in and discussed the transition with the provider and acting manager. There was a comprehensive assessments completed by both the home and the funding authority. As people who live at the home have complex needs each admission was planned to meet the needs of the individual and the other people who were already living at the home. We saw the records of the short visits and one overnight stay for the last person to move in. They gave a good clear account of how the individual was during their visits. Walc House DS0000070429.V377239.R01.S.doc Version 5.2 Page 10 Pictorial, photographic and written information was given to the two people about who was moving in to the home. All of the people who live at the home went to the same residential school so had some knowledge of each other before moving into the home. Walc House DS0000070429.V377239.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. Peoples’ needs and goals are reflected in good quality person centred plans. People are supported to make decisions and to take risks and this means that they live a full, active and independent lives. EVIDENCE: Two people’s care records were seen, the individual’s have complex ways of communicating their needs and this can present challenges for others. Each file contained a care plan detailing personal, health, social, communication and emotional care needs and how staff are to meet and support those needs. There are descriptions of how staff are to support people to make choices and decisions and promote their independence in their every day lives. There is a culture of positive risk taking for people. Communication cues and Makaton Walc House DS0000070429.V377239.R01.S.doc Version 5.2 Page 12 signing are used for some people to make sure that they are actively involved and informed of what is happening in their lives. There were clear records of any incidents of challenging behaviour with details of the circumstances and consequences. There is a positive culture in the home of encouraging independence and perceiving any behaviour in a positive way and that the individual is trying to communicate something that staff have not yet understood. For example we observed that one person wanted some tools. Staff supported them with finding a screwdriver, the individual then proceeded to unscrew signs from doors in the home. The staff viewed this is a positive meaningful activity for the individual as they were focused and occupied at a time when they could be over animated whilst waiting to go to their parents. The staff told us ‘we’ll just screw them back on it’s not a problem’. People’s risk assessments and care plans had been formally reviewed monthly and had also been amended as and when people’s needs have changed and or staff have found new things out about individuals. At the moment people are not involved in the reviewing of their care plans. Individual ways of including people in their monthly reviews and their care plans should be developed. This should include investigating different recording mediums such as photographs, communication in print, DVDs, audio and the computer. This is so people are involved with the records kept about them and have this information in a format or medium that is accessible to them. Body maps are completed following any accidents or incidents of self injurious behaviour. These should be dated so that they can be audited as part of monitoring systems at the home. There is a good shared photographic memory book for the there people who live at the home. Staff told us that one person likes to look at this. There is a culture of positive risk taking for people. Comprehensive risk assessments were in place for each person, their day to day lives and activities in the community. The provider, acting manager and staff spoken with were enthusiastic and had a very positive attitude on promoting people’s independence. Positive interactions and relationships were seen between the people and staff. People and staff clearly enjoyed each other’s company. The staff were positive about the strengths and skills of the people they support and all commented that they enjoy their time together. Walc House DS0000070429.V377239.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): This is what people staying in this care home experience: People using 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. The people living in this home are supported to make choices about their lifestyle and to develop life skills. Daily activities promote independence and opportunity for people to live ordinary and meaningful lives in the community where they are living. EVIDENCE: There is significant evidence in care plans, care records and photo memory book that people’s activities are wide and varied and meet their individual, social and cultural needs. From discussions with staff and the acting manager, people’s relationships with their families and friends are supported and maintained. People’s family members are actively consulted and involved in the care of their relative, this Walc House DS0000070429.V377239.R01.S.doc Version 5.2 Page 14 is particularly important as some of the people are not able to verbally communicate their views. At the time of the inspection one person was holiday with their parents and on the second day of inspection one person was having their regular weekly two night stay at their parents’ home. In the AQAA completed by the acting manager they told us that: ‘We support residents in their learning of living skills promoting opportunities throughout the day so as to enable the residents to become as independent as possible. We are good at modelling and mentoring skills to our residents and are constantly looking at ways to make our residents lives more independent, be it by acquiring specialist equipment that enables this development or introducing plans that can help support their development. We have purchased a variety of in-house entertainment for the residents. We have a large sunken trampoline in our sensory garden that can be accessed by all the residents if they so wish. A variety of puzzles and table games are also accessible as well as reading literature. We have also enabled one of our residents to enjoy the use of their personal lap top wherever in the building by setting up a wireless system’. People are supported in accessing a wide variety of services and facilities within the community such as shops, cinemas, libraries, leisure centres, and cultural centres such as museums. People living at the home have a group membership at a local health club and access to a local National Trust beach hut. One person is being supported by their family to worship when they are at the family home. The individual has not communicated that they want to worship whilst at the home. One person has a job at a local café and work opportunities are being investigated for the two other people. The records show that people are provided with a well-balanced and nutritious diet. All food being stored in the kitchen looked fresh and was well within the use by date. People go food shopping with staff support at least once a week. People are encouraged to participate in meal preparation and cooking. Individuals take it in turns to choose the main meals. People are encouraged to take part in the day to running and cleaning of the home. Individuals do their own laundry and did try to do their own ironing with staff support. However, following a reassessment of the risks, staff now do the ironing. Walc House DS0000070429.V377239.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. The health and personal care that people in this home receive is based on their individual needs. Staff respect the people and promote their dignity and privacy. Medication systems in place are safe. EVIDENCE: There were positive relationships and interactions observed between staff and the people who live at the home. Staff respected when people wanted their own space whilst encouraging them to be occupied. People and staff clearly enjoyed each other’s company, smiled, and laughed with each other. When asked about staff, one person signed ‘good’ and said ‘yes’. All three of the people have autism and behaviours that challenge and have either limited or no verbal communication. There are very clear behaviour management plans in place that are based on defence and diffusion techniques, staff observed were calm relaxed and consistent in the way the Walc House DS0000070429.V377239.R01.S.doc Version 5.2 Page 16 worked and approached individuals. From discussion with the acting manager, and provider, physical interventions are very rarely used and then only ‘touch control’. The incident log supports these statements. There is a very positive attitude and focus on the individual’s strengths and abilities and not their behaviours. This is good practice. People’s health records and care plans showed that their right to good-quality physical and mental health care is being promoted. The records show that as part of promoting their health people make regular visits to a dentist, optician, specific health consultants, speech and language therapists, and their GP when needed. One person has been referred to see a neurologist following an increase in their seizures. Medication policies and procedures continue to be largely safe, with medication being stored safely and labeled correctly. There are good descriptions of how to people like to take their medication and epilepsy management plans in place. Staff have been trained in the administration of medication. The medication administration and storage seen was correct. Two of the people have regular visits and stays at their parents and they take their medication with them. This has not been recorded on the medication administration record. They spaces have just been left blank and no code has been entered. This makes it difficult to audit and establish whether the medication has not been administered or the person is not at the home. A number of people have ‘as required’ medication prescribed. There must be PRN (as needed) medication plans in place. These plans need to include under what circumstances it is to be given, how long between doses, what is the maximum dose in 24 hours and whether it can be taken with other medications. These should be agreed with the prescribing practitioners or learning disability health practitioners where possible. It is recommended that these plans be kept with the administration records so that staff can easily refer to them. Walc House DS0000070429.V377239.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. Complaints procedures make sure that peoples’ relatives and representatives concerns and complaints are listened to and acted upon. The shortfalls in staff’s knowledge and understanding of the home’s adult protection safeguarding procedures means that allegations may not be reported to the relevant authorities. EVIDENCE: There have been no complaints made to the Commission about the home since the last inspection. There is a written complaints procedure that is available to people and their families or representatives. The contact details of the commission should be updated to make sure that people and know how to contact us. We looked at the complaint log; there was a record of one complaint, the investigation and outcome. As people who live at the home communicate in complex ways, written and or pictorial information is not necessarily accessible to all of them. There are Walc House DS0000070429.V377239.R01.S.doc Version 5.2 Page 18 good descriptions in people’s plans as to how they let people know when they are unhappy and unsettled. Further consideration should be given to developing ways of each individual having accessible information about how they can complain or let staff know they are unhappy. Observation of people showed that they felt calm and relaxed with the staff supporting them. This may indicate that they feel safe with the staff. Staff have been provided with adult protection and safeguarding information during their induction programme. We looked at the adult protection procedure available at the home. It was very complicated and did not give staff clear direction as to how to report any allegations of abuse and did not include the correct contact details for the local authority or commission. There must be a clear adult protection and safeguarding procedure that is easy for staff to follow. This is so they know how and to whom they can report any allegations of abuse. There should also be safeguarding information made available to the people who live at the home in a format that is accessible to each individual. This is so that they know who they can communicate with if they don’t feel safe or they are worried about abuse. During discussion with the acting manager and provider they told us about an incident where one person had punched another person. This was an isolated incident and actions have been taken to reduce the recurrence where possible. However, this had not been reported to us under regulation 37 or to the local authority under safeguarding procedures. The acting manager and provider were not clear that this would need to be reported and interpreted it as part of the individual’s behaviour. Incidents where people are physically aggressive and harm other people at the home must be reported to us under regulation 37. A referral must also be made to the local authority so they can determine whether it needs investigating. The acting manager and provider told us that they need to review and update many of the protection policies and procedures following the departure of the previous manager. At the moment there is a physical intervention policy in place. The provider anticipates that following training from a BILD ( British Institute of Learning Disabilities) accredited trainer that individual intervention plans can be developed that do not involve any physical intervention. Walc House DS0000070429.V377239.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. The home is well maintained and furnished so that people live in a clean, comfortable environment. EVIDENCE: Walc House is a large terraced property in a residential street in Swanage. The property is in-keeping with other houses in the road. Car parking is available on the street outside the house. There is an enclosed landscaped garden to the rear of the house with a seating area, sunken trampoline and a border. One person was observed to dig over the border with great enthusiasm. Accommodation is on four floors. On the lower ground floor there is a large kitchen and adjacent WC. The lounge and office space is on the ground floor. There are two bedrooms on the first floor and one on the second floor of the Walc House DS0000070429.V377239.R01.S.doc Version 5.2 Page 20 home. All three bedrooms have an en-suite shower and toilet facility. A communal bathroom is situated on the first floor for use by residents. There is a separate lounge area on the second floor of the house that two of the people use and is used by the visiting therapist. The environment has been adapted to withstand the heavy wear and tear from some of the people who live there. There are specialist Perspex windows and the television and shelving in the main lounge are behind Perspex. There are radiator covers in place that reduce the incidents of damage to pipe work and the radiators. On person’s bedroom has cladding on the walls to reduce the impact of any self injurious behaviour. All of the bedrooms are very personalised and people have chosen the colours and furnishings. There has been excellent work with one individual encouraging them to keep furnishings and items in their bedroom. Staff has spent time with them in their bedroom in the evenings to promote positive feelings about the space. There is a warm and welcoming atmosphere in the home and at the time of the visits, it was homely, comfortable and safe. People living there were able to move around easily and freely and to go to their bedrooms if they chose. People at the home are involved in cleaning and tidying alongside staff. The staff help them with their laundry. The home is very well maintained and reflects the personalities and interests of the three people who live there. Walc House DS0000070429.V377239.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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. The people living in this home are protected by robust recruitment practices and supported by a skilled and competent staff team. EVIDENCE: The staffing levels at the home are individual negotiated for each person by their funding authority. There are a minimum of four staff on duty (including the manager) during the waking day and two waking night staff. The home has a low turnover of staff with only a few staff leaving since the last inspection including the registered manager. Staff sickness levels are also low and this means that a consistent staff team that they know well supports the people living at the home. This is particularly important as people living at the home have very complex needs and ways of communicating. Walc House DS0000070429.V377239.R01.S.doc Version 5.2 Page 22 The acting manager told us during the inspection and in the AQAA that they trialling a new shift pattern. Staff work four long days on and have four days off. This means that the people at the home have a consistent staff team without shift changeovers. This has been very important for the people at the home who found these times difficult and that staff have a long rest period after working four days. The new shift pattern will be reviewed after three months. We looked at three staff files for the most recently recruited staff. The member of staff recruited by the previous manager included CRB and POVA checks but only included one reference. The staff recruited by the acting manager included all of the checks and references required. The staff files are now well organised. Written references should be verified by telephone. This is to make sure that references are from a person who has managed the staff member. The acting manager told us in the AQAA that: ‘Staff have been enrolled in NCFE courses(Health and Nutrition, Occupational Health and Safety or Equality and Diversity) with Somerset College and those that have only level 2 NVQ or have no NVQ have been enrolled with Weymouth College to achieve this qualification’. There is a comprehensive induction programme that meets skills for care induction standards. Staff have accessed training in the full range of mandatory, health and safety related training, (e.g. first aid, food hygiene and fire safety) as well as specialist care courses, such as autism and epilepsy. Staff records told us that staff have regular supervision. There are staff team meetings every month and the minutes of these were seen. Walc House DS0000070429.V377239.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using 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 benefit from living in a suitably run home. Peoples’ best interests are promoted. EVIDENCE: Since the last inspection there have been some management changes at the home. The registered manager left the home in June 2009. The deputy manager is now acting manager. The acting manager and provider are now spending time reviewing and organising the management of the home. They have identified a number of shortfalls and plan to implement a Quality Assurance system that will monitor and improve the service. Walc House DS0000070429.V377239.R01.S.doc Version 5.2 Page 24 The acting manager completed the AQAA (Annual Quality Assurance Assessment) to a high standard and was able to identify what the home does well, how they can evidence this and identified areas for improvement. The provider is looking at using regulation 26 visits as a more effective way of monitoring the records kept at the home. There are regular meetings with the people who live at the home and they are consulted about things that are important to them. Minutes of the meetings are produced supported by pictures. At the moment there is not any auditing or monitoring of incidents, accidents, self injurious behaviours, care plans and medication. These should regularly reviewed and monitored to establish whether there are any patterns, trends or shortfalls that may impact on the people who live at the home. Information provided before the inspection, by the manager in the AQAA (Annual Quality Assurance Assessment) indicates that relevant Health and Safety checks and maintenance are being carried out at the home. A number of Health and Safety records were checked, including the fire safety log. These records showed that health and safety matters are well managed. However, the fire risk assessment in place at the home is only a tick checklist and does not include any details or descriptions of the actions that need to be taken in the event of a fire. Walc House DS0000070429.V377239.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 x 2 3 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 2 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 x x x 2 3 Version 5.2 Page 26 Walc House DS0000070429.V377239.R01.S.doc No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13 Requirement There must be PRN (as needed) medication plans in place. These plans need to include under what circumstances it is to be given, how long between doses, what is the maximum dose in 24 hours and whether it can be taken with other medications. This is to make sure that staff know in what circumstances to administer ‘as need’ medications and the maximum dosage people can safely be given at any time. 2 YA23 13 There must be a clear adult protection and safeguarding procedure that is easy for staff to follow. This is so they know how and to whom they can report any allegations of abuse. 3 YA23 13, 37 Incidents where people are physically aggressive and harm other people at the home must be reported to the commission DS0000070429.V377239.R01.S.doc Timescale for action 01/10/09 01/10/09 01/09/09 Walc House Version 5.2 Page 27 under regulation 37 and to the local authority under adult protection safeguarding procedures. This is to make sure that any allegations are appropriately investigated and actions taken to safeguard the people living at the home. 4 YA42 23 A fire risk assessment must be place that includes: The fire hazards you have identified, The actions you have taken or will take to remove or reduce the chance of a fire occurring, Persons who may be at risk, particularly those especially at risk. The actions you have taken or will take to reduce the risk to people from the spread of fire and smoke (protective measures). The actions people need to take in case of fire including details of any person nominated to carry out a particular function (your emergency plan). The information, instruction and training you have identified that people need and how it will be given. This is to ensure the fire safety at the home. 01/10/09 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 YA6 Good Practice Recommendations These should be dated so that they can be audited as part DS0000070429.V377239.R01.S.doc Version 5.2 Page 28 Walc House 2 YA6 of monitoring systems at the home. Individual ways of including people in their monthly reviews and their care plans should be developed. This should include investigating different recording mediums such as photographs, communication in print, DVDs, audio and the computer. This is so people are involved with the records kept about them and have this information in a format or medium that is accessible to them. Body Maps should be dated so that they can be audited as part of monitoring systems at the home. Medication Administration records must be completed with the appropriate code when people are away from the home. This is so that there is a clear record and audit trail. Further consideration should be given to developing ways of each individual having accessible information about how they can complain or let staff know they are unhappy. Safeguarding information should be made available to the people who live at the home in a format that is accessible to each individual. This is so that they know who they can communicate with if they don’t feel safe or they are worried about abuse. Written references should be verified by telephone. This is to make sure that references are from a person who has managed the staff member. The monthly auditing and monitoring of incidents, accidents, self injurious behaviours, care plans and medication should be implemented. This is to establish and monitor whether there are any patterns, trends or shortfalls that may impact on the people who live at the home. 3 4 5 6 YA6 YA20 YA22 YA23 7 8 YA34 YA39 Walc House DS0000070429.V377239.R01.S.doc Version 5.2 Page 29 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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