Inspection on 14/09/04 for Weymouth AfterCare Centre

Care Homes For Adults (18 ­ 65)Weymouth Aftercare CentreCarlton House 9 Carlton Road North Weymouth Dorset DT4 7PXUnannounced Inspection14th September 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Weymouth Aftercare Centre Tel No: 01305 779084Address Fax No: Carlton House, 9 Carlton Road North, Weymouth, Dorset, DT4 01305 750879 7PX Email addressName of registered provider(s)/company (if applicable) Mr Trevor George Felgate Mrs Joy Marie Felgate Name of registered manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 15Category(ies) of registration, with (number of places) Past or present alcohol dependence (15), Past or present drug dependence (15) Registration number D080000418 Date first registered 20th January 1987 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 1st April 2002 YES NO 21/04/04 If Yes refer to Part CWeymouth Aftercare CentrePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 314th September 2004 11:00 am Julia MooneyID Code072711Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMr Trevor FelgateWeymouth Aftercare CentrePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementWeymouth Aftercare CentrePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Weymouth Aftercare Centre. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Weymouth Aftercare CentrePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Weymouth Aftercare Centre is a private care home that provides a residential rehabilitation programme for men suffering from alcohol or drug dependency problems. It is situated in a quiet residential area of Weymouth within easy walking distance of the seafront and local amenities. It has been established as a care home for approximately 15 years and retains strong links with the local community. The Centre accepts service users from any part of the country. Ordinarily, service users are admitted from a primary care unit, where treatment has already commenced. In a minority of cases service users may come directly from prison or may be subject to a probation order. Placements are of a short-term nature, ordinarily approximately of three months duration. Service users either then return to their own area or move on to a half-way house in Weymouth. Service users are encouraged to take responsibility for their own recovery. The emphasis is on participation in daily activities, household chores and group meetings. Staff provide support through individual and group counselling sessions. Service users are expected to comply with the structured programme. In pursuance of the goals that service users are seeking to achieve, certain rules and restrictions are in place which limit individual freedom. Service users formally agree to these arrangements prior to admission.Weymouth Aftercare CentrePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) Choice of Home (Standards 1-5) 3 of the 5 standards assessed were met. Mr Felgate produced a Statement of Purpose/Service Users Guide which was examined by the inspector during the last inspection in April 2004. It contained relevant information about the home, including the aims, objectives facilities and services. However, Mr Felgate was informed that minor alterations and additional information was required in order for the document to meet statutory requirements. An updated Statement of Purpose/Service Users Guide was not available at this inspection. Mr Felgate stated that the document was at his home. He was advised to forward a copy to the Commission for Social Care Inspection within the time scale specified in this report. Mr Felgate was reminded that the National Care Standards Commission now operates as the Commission for Social Care Inspection so this document (and all others) needs to be changed to this effect. Assessments are ordinarily done on the premises over a 24 hour period. In the majority of cases prospective service users have already been assessed by a relevant professional prior to referral to the home. Any special needs or restrictions are discussed and agreed by all relevant parties, prior to commencement of placement. The home only admits those people for whom it can offer an effective service. Service users are provided with written information about the nature of the recovery/rehabilitation programme prior to admission. Placement agreements are confirmed in writing with the referring agency. A trial period of 2 - 3 weeks is continually assessed by staff and the service user. Service users are funded by an external agency and therefore there is a written contract between the home and the placing agency. Mr Felgate has briefly referenced the terms and conditions, and cost of staying at Weymouth Aftercare in a section headed Finances in the Statement of Purpose. At the last inspection the inspector advised Mr Felgate that it did not meet the standard to produce a costed contract between the home and the service user. An updated version was not available for this inspection. Mr Felgate stated that the document was at his home. He was advised to forward a copy to the Commission for Social Care Inspection within the time scale specified in this report. Individual Needs & Choices (Standards 6-10) 4 of the 5 standards assessed were met. Each service user has a care plan. There is a section for identified needs, goals, and tasks to achieve those goals. The plan reminds the person(s) completing it to take into consideration the religious and cultural needs of the individual. The inspector examined a sample of care plans and found reference to attendance at college and voluntary work placements but there was no section outlining the family/social support for that individual. As family/social support is crucial for those in treatment for addictive disorders, it would be beneficial to have a section in the care plan for this purpose (For requirement see Standard 15). The care plans were signed and dated by the staff member and the service user. The plans evidenced frequent reviews by the service user and staff member although Mr Felgate explained that it was not always possible to engage Care Managers in reviewing the plan. Weymouth Aftercare Centre Page 6 However, written summaries are provided by the home on the service users departure or at other significant intervals. The home works with service users in a particular way. Service users complete a weekly self assessment document. These assessments are shared with their peers in group discussions. A personal review takes place once a month, this involves the service user completing part of the review, the peer group also review progress and there is feedback from staff. The group may identify an area of concern for a particular individual. Service users hold monthly household meetings to discuss issues relating to the running of the home. Risk assessments form part of the care plan. The inspector examined three risk assessments and noted that staff sign the document but service users did not. The last inspection found similar findings. Staff must ensure that information in risk assessments is shared with the respective service user and signed by both the service user and staff member. At the last inspection, the inspector advised Mr Felgate to reference Orders and restrictions imposed by the Courts under the Criminal Justice Act, in the homes Statement of Purpose and Service Users Guide. As the updated version was not available on this occasion, the requirement is repeated. The home places emphasis on respecting service users confidentiality. There is a policy on the issue of confidentiality and access to service users personal records. Lifestyle (Standards 11-17) 5 of the 7 standards assessed were met. Service users are encouraged to take responsibility for their own recovery and development. Staff provide the therapeutic input through group or individual 1-1 counselling. More specialist input is also provided, according to assessed need. Outside of the counselling programme there are structured activities designed to enable service users to obtain/re-learn the necessary skills to successfully integrate with the community. Use is made of Weymouth College to assist in the running of relevant programmes. Mr Felgate stated that a few service users have expressed an interest in attending Literacy courses starting later this month and a small number wish to attend a Life Skills course. The inspector found reference to service users being involved in education and voluntary work placements in individual plans. The home has strong and long-standing links with the local community. Service users have immediate access to the NA and AA meetings which take place in different settings in the town. The home maintains contact with ex service users who remain in the locality and offers a regular weekly aftercare follow-up group meeting. Service users have access to and are encouraged to use the local amenities and public transport. The registered providers purchased a new minibus last November and places visited recently include West Bay and Portland. Staff are on duty at all times to assist service users, where needed. The inspector was particularly impressed with evidence (a comprehensive file) that service users have participated in a wide range of community projects throughout the year. Many were Charitable Events and all benefited the community. From speaking with service users, the events were also beneficial to them, many spoke of giving something back. Service users contact with family/friends is encouraged and maintained either by phone or by visits. This is achieved through a planned process and varies according to individual circumstances. The homes communal areas can be used for visits. However, the inspector was unable to find reference to maintaining family links and friendships in service users individual plans. This was raised with the registered provider during the last inspection so every effort must be made to ensure that this forms part of the care plan for each service user in the time specified in this report. The requirement is repeated on this occasion. The homes rules and routines are geared towards the achievement of the service users Weymouth Aftercare Centre Page 7 goals i.e. sustaining a lifestyle which is free of chemical dependency. This includes the building up of trust amongst peers and developing self-confidence. It also includes carrying out domestic and household tasks. Service users are discouraged from isolating themselves by spending prolonged periods in their bedroom. Locks are not fitted to bedroom doors, as would ordinarily be expected in a care home and there is no lockable space in each bedroom. Previous inspections have highlighted the need for the rationale for this to be referenced in the homes new Statement of Purpose/Service Users Guide. As the updated version of the Statement of Purpose/Service Users Guide was not available for inspection, the recommendation is repeated on this occasion. The home takes care to provide a nutritious and varied diet; full account is taken of specific dietary requirements. The menu rota is changed approximately every 3 weeks. Choice of main meal items is limited but account is taken of individual likes and dislikes. Food and meals are supplied at appropriate intervals and in suitable quantities. There are opportunities to discuss the menu content at meetings. Hot and cold drinks are freely available. Service users are not directly involved in meal planning and preparation, this being the preferred policy of the management. Personal Healthcare & Support (Standards 18-21) 4 of the 4 standards assessed were met. The service users are able-bodied and are not in need of hands-on personal care. Support and guidance is provided by staff in accordance with therapeutic principles. The general atmosphere and social environment is an inclusive one; service users are treated as responsible adults. All service users are registered with one local GP surgery where the doctors have a specific interest in the relevant client group. In view of the short-term nature of placements such an arrangement is acceptable. The home ensures that service users have access to all relevant healthcare facilities, including specialist outpatients appointments and visits to dentists. Service users are accompanied to appointments where necessary. The homes accident book was satisfactorily maintained. The inspector examined the homes medication storage and recording. Medication is kept in a small room off the kitchen and keys are kept nearby in private staff quarters which can be accessed by all staff administering medication. The home is currently retaining medication for 7 service users and records pertaining to these individuals were well recorded. Other records examined included medicines received and disposed of. They were sufficiently detailed and adequately maintained. The home obtains the Pharmacists stamp to agree what medication was returned to them for disposal. Four staff are attending a 12 week course on Medicines Administration. The homes policy and procedure on medication has been updated in accordance with a requirement made as a result of the last inspection. It now makes reference to receipt and disposal of medication and reference to service users who self-medicate. In view of the relative youth of the service users at the home such an occurrence is an unlikely event. The home has a policy and procedure for staff to follow in the event of a death occurring at Weymouth Aftercare Centre. The admission documentation takes into account the service users religious beliefs. Complaints & Protection (Standards 22-23) 1 of the 2 standards assessed were met. The home now has a complaints log and no complaints had been made since the last inspection. A requirement that the record be checked and signed by the registered provider at least every 3 months has been achieved since the last inspection. The homes complaint procedure was adequate and contained in the terms and conditions of residence document, it includes the advice that a complainant may make direct representations to the Commission for Social Care Inspection. There have been no reported incidents of suspected abuse. With the spirit of openness Weymouth Aftercare Centre Page 8 which prevails in the home and the informality in the relationships between staff and service users this is not an environment in which abuse is likely to prosper. Mr. Felgate has now produced an Adult Protection policy and procedure, although it would benefit from a clearer definition of what Adult Protection means. A Whistle Blowing policy and a policy on handling aggression is in place at the home and staff have had in ­ house training from Mr. Felgate on the issue of restraint. Environment (Standards 24-30) 4 of the 6 standards assessed were met. The home is located within walking distance of Weymouth town centre where there are a range of amenities and facilities. The property has a pleasant garden and casual sitting area (partially enclosed) to the rear of the building. A ground floor rear extension has been in the early stages of construction for several years. Mr Felgate informed the inspector at the last inspection that he made the decision to continue with the original plan of a single storey extension to provide an extended office, a quiet room, and an extended dinning room to offer a larger communal space with access to the garden area. Mr Felgate further stated in April that a meeting with the builder was scheduled for early in May. He agreed to inform the Commission for Social Care Inspection of the discussion and notify any alteration/change to the property. He failed to do this, so the recommendation for the registered provider to produce a realistic timetable for completing the building work at the home, is therefore repeated on this occasion. The home benefits from a planned programme of re-decoration, renewals and repairs and maintenance records were available for inspection. There is a predominance of shared bedrooms. The registered providers view is that such an arrangement accords with the homes philosophy and aims and objectives. In accordance with a recommendation first made in 2002, shared bedrooms are currently being fitted with suitable screening to ensure a degree of privacy for the occupants. The inspector advised the registered provider to purchase free - standing screens for the three rooms with sloping ceilings. The largest shared room has a third bed (and accompanying furniture). This bed is used if overnight stays are required for prospective service users attending for assessment. The inspector spoke with the occupants of this room who had no problem with the arrangement and stated that their permission is always sought before a prospective service user is offered overnight accommodation. The registered providers attempts at upgrading Weymouth Aftercare Centre over the past year are commendable. Each bedroom now has had new bedding and curtains, one bedroom has new furniture and three bedrooms have been redecorated. One bedroom has new carpet and the second floor bathroom has new flooring. The lounge and dinning room have also been decorated recently. All bedrooms had radiators which have been fitted with thermostatic control valves to allow the occupant to control the temperature in his room. Each bedroom now has at least 2 double sockets. The home has 5 toilets and 2 bathrooms. The facilities were found to be clean and fit for the purpose. There are a total of three communal rooms, including a dining room which has a computer for service users, a library area which is designated as the smoking area and a lounge. One room can be set aside for service users to receive visitors in private, although it is not specifically for this purpose. Two of the rooms are suitable for group meetings. There is a payphone in the hallway for general use. The office telephone is used for private calls to such people as Social Workers and Probation Officers. The home was found to be clean. The service users clean their bedrooms and most communal areas, under the overall supervision of the staff. There are no laundry facilities on the premises. Information on laundry arrangements should feature in the homes statement of purpose. Service users are provided with money to do their personal laundry in a nearby Weymouth Aftercare Centre Page 9 laundrette, whilst bed linen is cleaned via an external laundry service. This arrangement is in accordance with the homes philosophy of assisting the recovery process and encouraging service users to make use of community resources. Staffing (Standards 31-36) 3 of the 6 standards assessed were met. Staff demonstrated that they had a clear understanding of their role and of the aims of the home. Suitable therapeutic relationships are established between staff and service users and there is a good level of empathy and understanding of issues relating to substance abuse. The last two inspections have highlighted the need for staff to have formal job descriptions. At todays inspection some were available for examination. Mr. Felgate has put considerable effort into this task and all job descriptions examined were appropriate. Staff have relevant experience and those involved in counselling either have a qualification or are working towards achieving this. Staff have other qualifications relating to health and safety and to running a care home. Since the last inspection one member of staff has obtained NVQ 2 qualification. Mr Felgate stated that a further two members of staff are likely to commence NVQ level 2 training in September 2004. In addition to the registered providers (who work part time hours) the home has a senior counsellor, 2 counsellors, 2 support workers one of whom assists with cooking when the main cook is away. The staff group are effective with the majority having been in post for several years. A weekly record of staffing arrangements is maintained. Staffing arrangements are made according to the assessed needs of the service users; currently, dependency levels are not calculated in accordance with Department of Health guidance. A requirement was made as a result of the last inspection for Mr Felgate to purchase the Residential Forum Calculator from the Social Care Association and calculate the total number of hours needed in accordance with the assessed dependency levels of service users, with the total number of staff hours currently provided at the home. This has not been achieved so the requirement is repeated on this occasion. Mr Felgate should ensure that the Calculator is purchased and used by the time specified in this report. Staff meet on a daily basis and more recently a meeting has been introduced on the last Thursday of the month. However, this meeting is not recorded or actioned so for the fourth time, this recommendation is repeated. The registered providers must ensure that staff meetings take place at least 6 times a year and that these meetings are recorded and actioned. Written evidence suggests that the homes recruitment policy and procedure is slowly improved with each inspection. Mr Felgate acknowledged that further work was required in order to fully meet this standard. New contracts and terms and conditions of employment are still to be introduced. As on the last occasion, the inspector advised that a minimum of 3 months probationary period and at least 5 days training (pro-rata) be added. Mr Felgate reported that no new appointments had been made since April 2002. As the majority of staff members have been in post for several years, their application form and record of references may not have been retained. Police checks via the Criminal Records Bureau on all existing staff members have been applied for but given the length of time it is taking for their return, the registered provider should chase them. Given the short-term nature of service user placements at the home it would not be appropriate to involve them formally in the staff recruitment procedure. The registered providers must have a robust recruitment procedure to include volunteers. The procedure for future staff (and volunteers) should involve a written application form, formal interview, two written references and a satisfactory check from the criminal record bureau. Each member of staff must have in their personal file, a recent photograph and documentary evidence of their qualifications. They should also have a formal contract stating the terms and conditions of their employment and be given a copy of the homes disciplinary and grievance procedures and the General Social Care Council code of practice. Since the Weymouth Aftercare Centre Page 10 last inspection Mr. Felgate has purchased copies of the General Social Care Council code of practice which relates to standards of conduct in the caring profession. All staff are expected to adhere to these standards. Mr. Felgate in conjunction with Weymouth College Assessment Team has conducted a training needs analysis for the team. Staff have personal training files that were very well maintained with certificates in place. Mr. Felgate was unable to evidence that formal staff supervision was taking place for all staff. Three members of staff had a supervision record, however, three did not. Mr Felgate has been particularly slow in his attempts to meet this standard which was first brought to his attention in December 2002. He stated that until now supervision has been with external counsellors to assist staff with their professional practice and development. The registered providers have been paying for this facility. In order to prevent enforcement action being taken, the registered providers must ensure that staff supervision takes place at least 6 times a year within the time scale specified in this report. A record must be maintained and the supervisee must be given a copy. The sessions should address the individuals training needs and personal development plan. The registered providers should refer to the National Minimum Standards ­ Care Homes for Adults, for guidance. Staff annual appraisals are ongoing and were available for inspection. Conduct and Management of the Home (Standards 37-43) 2 of the 7 standards assessed were met. The registered providers, Mr and Mrs Felgate, have several years experience of managing a care home. Neither has obtained NVQ level 4 in management and care but it is their intention for one of them to achieve it prior to 2005. In addition to a counselling qualification, Mr Felgate has a certificate in education. Dominic Castle, the senior counsellor also assists with managerial tasks at the home. The registered provider should given consideration to the appointment of a registered manager for the home. The structure of the home lends itself to an open style of management. The atmosphere in the home on the day of the inspection was positive and productive. The inspector witnessed staff treating service users with respect throughout the day. Service users spoken with considered that staff were approachable and they felt comfortable about expressing views and making suggestions. The main vehicle for instigating change and development is through the various group settings and meetings which take place on most days. The last two inspections have highlighted the need for the home to have a quality assurance system. At the last inspection Mr Felgate evidenced that he had started to address this matter with the issuing of a feedback form to service users once a month. However, they have not been used regularly and neither has a similar form specifically designed for others eg. Relatives and Care Managers etc. The registered providers must introduce a formalised system to monitor quality assurance at the home within the time scale specified in this report. Failure to do so may result in enforcement action being taken. The inspector sought comments from the service users and Care Managers for this inspection. To date there has been no responses from Care Managers. The inspector spoke with all service users as a group. They made positive comments about the care, facilities and services at Weymouth After Care Centre and stated that the treatment on offer at the home was excellent and that staff were very caring and knowledgable. Service users are able to access their records at any time and are fully aware of what is written in their file. Individual records are secure in the office. The inspector examined fire records and found them to be unsatisfactory.A fire drill was overdue and there was no evidence of fire training for staff having taken place since the last inspection. Mr Felgate stated that training had taken place but the record could not be located whilst the inspector was on the premises. Similar findings have been found in the Weymouth Aftercare Centre Page 11 past. An immediate requirement was issued to Mr Felgate giving him 7 days to evidence that a fire drill and fire training for staff has taken place. Mr Felgate has since provided evidence of this within the time specified. With immediate effect, the registered providers must ensure that all staff receive training every 6 months (every 3 months for night staff) and that the content of the fire training session is recorded. The record must evidence a staff signature to verify who attended the training. Measures and systems are in place to cover most aspects of health and safety, including the regular servicing of most of the installations and equipment and staff training. The homes electrical and gas certificates were valid as was the portable appliance test certificate. There have been no reportable accidents, injuries, illness or communicable disease or the death of a service user at Weymouth After Care since the last inspection. Water temperatures at the home are still not recorded despite a recommendation being made at the last three inspections. A record must be kept, the boiler must be 60 degrees to prevent Legionella disease and around 43 degrees at the outlets. The registered provider is advised to either complete risk assessments for each service user in respect of water temperatures if the current temperature exceeds 43 degrees, or fit regulator valves to hot water taps to ensure that the water is around 43 degrees. Caution Hot Water stickers have been fixed near wash hand basins. The recommendation is repeated on this occasion. The registered providers should provide evidence that the home has had a water test for Legionella Disease. The home has been inspected by an Environmental Health Officer since the last inspection. Four recommendations were made two of which have been addressed. Mr Felgate stated that in order to comply with the other two recommendations parts have been ordered from Canada. The registered provider reported that records of all business transactions were held and that an accountant conducted an annual audit of the accounts. To date a business and financial plan has not been produced despite it being made a requirement in December 2002 and repeated in May and October 2003 and April 2004. Mr. Felgate stated that he held a business meeting in May and a plan emerged from discussions at this meeting. He stated that evidence of this was held at his home. He was advised to forward a copy to the Commission for Social Care Inspection within the time scale specified in this report. Failure to do so may result in enforcement action being taken.Weymouth Aftercare CentrePage 12 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 4 YA1 The homes Statement of Purpose/Service Users Guide requires some re-arrangement of the text, minor amendments and additional information all of which can be better explained to the registered providers verbally with the documentation in front of them. Each service user must have a written and costed contract/statement of terms and conditions with the home. Original date for compliance was 31/03/04 3 13(4) YA9 All risk assessments must be signed by both service user and staff member. The assessment must outline the action necessary to minimise the risks identified The restrictions of those service users who are subject to Drug Treatment and Testing Orders should be documented as part of their risk assessment within the care plan. The homes Statement of Purpose/Service Users Guide must reference the fact that service users can be accepted as part of a Court Order subject to the restrictions imposed by the Court. 4 16(2) YA15 Service users individual plans shall include details of family links and significant friendships and level of contact service user wants. 31/08/04 31/08/04 31/08/0425YA531/08/04Weymouth Aftercare CentrePage 13 518(2)YA36The registered person must ensure that 31/08/04 persons working at the care home have regular supervision meetings at least six times a year. Staff shall have an annual appraisal with their senior manager to review performance against job descriptions and agree career development plans619(1)YA34The registered provider must ensure that all staff shall have a file containing their application form, two written references, interview notes, a contract of employment and terms and conditions of employment. All future staff appointments should be made on the basis of a minimum three month probationary period.31/08/04719 Schedule 2 19 Schedule 2 25YA34A recent photograph must form part of staff files. Original date for compliance was 31/03/0331/08/048YA34Police check on all existing staff members must be chased via the criminal record bureau Original date for compliance was 31/03/0331/08/049YA43The home should have an annual business and financial plan available for inspection.31/08/04Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 2 3 4 YA16 YA24 YA32 YA33 The rational for the lack of provision of locks on bedroom doors and a lockable space in bedrooms should appear in the statement of purpose The registered provider should produce a realistic timetable for completing the building work at the home. The registered provider should make provision regarding training for NVQ level 2 for 50 of care staff. Qualifications must be gained by 2005. It is recommended that staff meetings (a minimum of 6 per year) be recorded and actioned. Page 14Weymouth Aftercare Centre 5YA37The registered provider should give consideration to the appointment of a manager for the home. Alternatively, Mr or Mrs Felgate should consider enrolling on the NVQ 4 training course in management and care. The home should regularly record water temperatures and consider fitting temperature control valves to hot water taps in the bathrooms at Weymouth Aftercare Centre6YA42CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). NONEMET (YES/NO)Weymouth Aftercare CentrePage 15 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The homes Statement of Purpose/Service Users Guide requires some re-arrangement of the text, minor amendments and additional information all of which can be better explained to the registered providers verbally with the documentation in front of them. Original date for compliance was 30/08/04 Each service user must have a written and costed contract/statement of terms and conditions with the home. Original date for compliance was 31/03/04 All risk assessment must be signed by both service user and staff member. The assessment must outline the action necessary to minimise the risks identified The restrictions of those service users who are subject to Drug Treatment and Testing Orders should be documented as part of their risk assessment within the care plan. The homes Statement of Purpose/Service Users Guide must reference the fact that service users can be accepted as part of a Court Order subject to the restrictions imposed by the Court. Original date for compliance was 31/03/04 Weymouth Aftercare Centre Page 1614YA131/03/0525YA531/03/05313(4)YA931/03/05 416(2)YA15Service users individual plans shall include details of family links and significant friendships and level of contact service user wants. Original date for compliance was 31/03/04 The registered providers must calculate the total number of hours needed in accordance with the assessed dependency levels of service users, with the total number of staff hours currently provided at the home in accordance with the Department of Health Guidelines. The Residential Forum Calculator is available from the Social Care Association to calculate this figure. Original date for compliance was 30/08/04 The registered person must ensure that persons working at the care home have regular supervision meetings at least six times a year. Original date for compliance was 31/03/04 The registered provider must ensure that all future staff shall have a file containing their application form, two written references, interview notes, a contract of employment and terms and conditions of employment. Existing staff shall have a contract of employment and terms and conditions of employment. All future staff appointments should be made on the basis of a minimum three month probationary period. Original date for compliance was 31/03/04.31/03/05518(1)(a)YA3331/03/0518(2)YA3631/03/05619(1)YA3431/03/0519 YA34 Schedule 2A recent photograph must be available in each persons file. Original date for compliance was 31/03/03 Police checks on all staff members must be pursued by the registered providers via the criminal record bureau Original date for compliance was 31/03/0331/03/0519 YA34 Schedule 231/03/05Weymouth Aftercare CentrePage 17 724YA39The registered providers must implement the homes quality assurance system. (Use of surveys). The outcome from all surveys should indicate success in achieving the homes aims and objectives and inform future planning. Original date for compliance was 30/08/04 An immediate requirement was issued to the registered providers giving them 7 days to evidence that a fire drill and fire training for staff has taken place. Mr Felgate provided evidence of this within the time specified in this report.31/03/05823(4)YA41 The registered providers must ensure that all staff receive training every 6 months (every 3 months for night staff) and that the content of the fire training session is recorded. The record must evidence a staff signature to verify who attended the training.23/09/04925YA43The home should have an annual business and financial plan available for inspection. Original date for compliance was 31/03/0431/03/05RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 2 3 4 YA16 YA23 YA24 YA25 The rational for the lack of provision of locks on bedroom doors and a lockable space in bedrooms should appear in the statement of purpose The homes Adult Protection policy and procedure would benefit from a clearer definition of what Adult Protection means. The registered provider should produce a realistic timetable for completing the building work at the home. The programme to provide screening to safeguard privacy in shared bedrooms should be completed by 31/03/05Weymouth Aftercare CentrePage 18 5YA32The registered provider should make provision regarding training for NVQ level 2 for 50 of care staff. Qualifications must be gained by 2005. It is recommended that staff meetings (a minimum of 6 per year) be recorded and actioned. The registered provider should give consideration to the appointment of a manager for the home. Alternatively, Mr or Mrs Felgate should consider enrolling on the NVQ 4 training course in management and care. The home should regularly record water temperatures and consider fitting temperature control valves to hot water taps in the bathrooms at Weymouth Aftercare Centre. The home must produce evidence that a water test for Legionella Disease has been conducted.6YA337YA378YA42* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: YES YES NO YES YES YES NO NO YES YES NO NO YES YES YES NO YES YES NO YESWeymouth Aftercare CentrePage 19 Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)14 X X YES NA YES YES 6 X 14/09/04 11:00 4.5The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Weymouth Aftercare CentrePage 20 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 385 385 Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are £20 per drug test 2 Key findings/Evidence Standard met? Mr Felgate produced a Statement of Purpose/Service Users Guide which was examined by the inspector during the last inspection in April 2004. It contained relevant information about the home, including the aims, objectives facilities and services. However, Mr Felgate was informed that minor alterations and additional information was required in order for the document to meet statutory requirements. An updated Statement of Purpose/Service Users Guide was not available at this inspection. Mr Felgate stated that the document was at his home. He was advised to forward a copy to the Commission for Social Care Inspection within the time scale specified in this report. Mr Felgate was reminded that the National Care Standards Commission now operates as the Commission for Social Care Inspection so this document (and all others) needs to be changed to this effect. For requirement see Regulation 4Weymouth Aftercare CentrePage 21 Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? Assessments are ordinarily done on the premises over a 24 hour period. In the majority of cases prospective service users have already been assessed by a relevant professional prior to referral to the home (e.g. care manager from Social Services or Probation Officer). Preliminary details are received either by telephone or by a report/letter from the referring agency or from the primary care centre where the service user is living. Any special needs or restrictions are discussed and agreed by all relevant parties, prior to commencement of placement. The referral form clearly states the outcome of this assessment. Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The home only admits those people for whom it can offer an effective service. This is achieved through the assessment process. Service users are provided with written information about the nature of the recovery/rehabilitation programme prior to admission. Placement agreements are confirmed in writing with the referring agency. Staff keep abreast of changes in the counselling field by periodic training and updating information through professional organisations. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? Wherever possible prospective service users visit the home to meet residents, staff and view the accommodation etc. If the service user wishes he/she can be accompanied by family, friends, Social Worker etc. A trial period is offered if, after discussion, it is felt that Weymouth Aftercare would benefit the prospective service user. A trial period of 2 ­ 3 weeks is continually assessed by staff and the service user.Weymouth Aftercare CentrePage 22 Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 2 Key findings/Evidence Standard met? Service users are funded by an external agency and therefore there is a written contract between the home and the placing agency. Mr. Felgate has briefly referenced the terms and conditions, and cost of staying at Weymouth Aftercare in a section headed Finances in the Statement of Purpose. At the last inspection the inspector advised Mr Felgate that it did not meet the standard to produce a costed contract between the home and the service user. An updated version was not available for this inspection. Mr Felgate stated that the document was at his home. He was advised to forward a copy to the Commission for Social Care Inspection within the time scale specified in this report. For requirement see Regulation 5Weymouth Aftercare CentrePage 23 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? Each service user has a care plan. There is a section for identified needs, goals, and tasks to achieve those goals. The plan reminds the person(s) completing it to take into consideration the religious and cultural needs of the individual. The inspector examined a sample of care plans and found reference to attendance at college and voluntary work placements but there was no section outlining the family/social support for that individual. As family/social support is crucial for those in treatment for addictive disorders, it would be beneficial to have a section in the care plan for this purpose (For requirement see Standard 15). The care plans were signed and dated by the staff member and the service user. The plans evidenced frequent reviews by the service user and staff member although Mr Felgate explained that it was not always possible to engage Care Managers in reviewing the plan. However, written summaries are provided by the home on the service users departure or at other significant intervals. The care plan review document was considered by the inspector to be a good example of progress and achievement by service users during their treatment programme at Weymouth Aftercare. It also highlighted any new goals and related to the original care plan. Risk assessments form part of the care plan. The home works with service users in a particular way. Service users complete a weekly self assessment document. These assessments are shared with their peers in group discussions. A personal review takes place once a month, this involves the service user completing part of the review, the peer group also review progress and there is feedback from staff. The group may identify an area of concern for a particular individual. This person is then expected to think about the concern and if he feels it would be of benefit to him, requests a mini ­ group where he can discuss the concern thoroughly with his peers and new goals are set. The home has a goals board on which goals are written to remind individuals of their own. Consequently, there is a high level of service user participation in the review process.Weymouth Aftercare CentrePage 24 Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? The principle of self-determination is intrinsic to the recovery programme. Service users retain responsibility for their own progress. Constraints may be in force if the service user is subject to a specific parole condition (if he is on early release from prison). The home is currently accommodating one person on such an order and records relating to this order were complete. Service users retain responsibility for Social Security benefits; the home does not act as appointee or agent. Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? There are limitations to which service users can usefully have an input into long-term management decisions given the short-term nature of placements. Monthly household meetings of service users take place to discuss issues relating to the running of the home. The daily group meetings are primarily therapeutic in nature, but may give rise to discussions about the structure of the recovery programme. Service users are able to access the homes policies and procedures if they request to do so.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 2 Key findings/Evidence Standard met? Risk assessments form part of the care plan. The inspector examined three risk assessments and noted that staff sign the document but service users did not. The last inspection found similar findings. Staff must ensure that information in risk assessments is shared with the respective service user and signed by both the service user and staff member. At the last inspection, the inspector advised Mr Felgate to reference Orders and restrictions imposed by the Courts under the Criminal Justice Act, in the homes Statement of Purpose and Service Users Guide. As the updated version was not available on this occasion, the requirement is repeated. For requirement see Regulation 13(4)Weymouth Aftercare CentrePage 25 Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? The home places emphasis on respecting service users confidentiality. There is a policy on the issue of confidentiality and access to service users personal records. There is also a statement on confidentiality that includes relevant information on the subject and references the Data Protection Act 1998. This statement lists persons who can access service users files for instance, Social Workers, Inspectors from the Commission for Social Care Inspection, Care Managers, Police Officers etc.Weymouth Aftercare CentrePage 26 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Service users are encouraged to take responsibility for their own recovery and development. Staff provide the therapeutic input through group or individual 1-1 counselling. More specialist input is also provided, according to assessed need. Service users are referred on to relevant agencies on completion of the recovery programme at the home.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? Outside of the counselling programme there are structured activities designed to enable service users to obtain/re-learn the necessary skills to successfully integrate with the community. Use is made of Weymouth College to assist in the running of relevant programmes. Mr Felgate stated that a few service users have expressed an interest in attending Literacy courses starting later this month and a small number wish to attend a Life Skills course. The inspector found reference to service users being involved in education and voluntary work placements in individual plans.Weymouth Aftercare CentrePage 27 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 4 Key findings/Evidence Standard met? The home has strong and long-standing links with the local community. Service users have immediate access to the NA and AA meetings which take place in different settings in the town. The home maintains contact with ex service users who remain in the locality and offers a regular weekly aftercare follow-up group meeting. Service users have access to and are encouraged to use the local amenities and public transport. The registered providers purchased a new minibus last November and places visited recently include West Bay and Portland. Staff are on duty at all times to assist service users, where needed. The inspector was particularly impressed with evidence (a comprehensive file) that service users have participated in a wide range of community projects throughout the year. Many were Charitable Events and all benefited the community. From speaking with service users, the events were also beneficial to them, many spoke of giving something back. Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? The emphasis is on service users taking the initiative to develop their own interests and resources. Staff encourage service users to pursue their leisure time constructively; service users response to this challenge is an indication of their therapeutic progress. The management has a range of contacts in the community which can assist in this respect, e.g. in the past fishing trips have been arranged for service users with a relevant interest. The home arranges access to sporting and health club facilities. Mr Felgate stated that walks around Weymouth Swannery and Portland, and Ten Pin Bowling have been enjoyed by service users in recent months. Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 2 Key findings/Evidence Standard met? Service users contact with family/friends is encouraged and maintained either by phone or by visits. This is achieved through a planned process and varies according to individual circumstances. The homes communal areas can be used for visits as bedrooms cannot be used for this purpose. The development of intimate personal relationships is not encouraged during service users stay at the home as this is considered to be an unhelpful distraction in the therapeutic process, this is stated in the homes Statement of Purpose/Service Users Guide. The inspector was unable to find reference to maintaining family links and friendships in service users individual plans but admission documentation clearly states the level of contact the service user wants. This was raised with the registered provider during the last inspection so every effort must be made to ensure that this forms part of the care plan for each service user in the time specified in this report. The requirement is repeated on this occasion. For requirement see Regulation 16(2)Weymouth Aftercare CentrePage 28 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 2 Key findings/Evidence Standard met? The homes rules and routines are geared towards the achievement of the service users goals i.e. sustaining a lifestyle which is free of chemical dependency. This includes the building up of trust amongst peers and developing self-confidence. It also includes carrying out domestic and household tasks. Service users are discouraged from isolating themselves by spending prolonged periods in their bedroom. Locks are not fitted to bedroom doors, as would ordinarily be expected in a care home and there is no lockable space in each bedroom. Previous inspections have highlighted the need for the rationale for this to be referenced in the homes new Statement of Purpose/Service Users Guide. As the updated version of the Statement of Purpose/Service Users Guide was not available for inspection, the recommendation is repeated on this occasion. For recommendation see YA16 Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The home takes care to provide a nutritious and varied diet; full account is taken of specific dietary requirements. The menu rota is changed approximately every 3 weeks. Choice of main meal items is limited but account is taken of individual likes and dislikes. A vegetarian option is always provided when vegetarian service users are resident. Food and meals are supplied at appropriate intervals and in suitable quantities. There are opportunities to discuss the menu content at meetings. Hot and cold drinks are freely available. Service users are not directly involved in meal planning and preparation, this being the preferred policy of the management.Weymouth Aftercare CentrePage 29 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? The service users are able-bodied and are not in need of hands-on personal care. Support and guidance is provided by staff in accordance with therapeutic principles. The general atmosphere and social environment is an inclusive one; service users are treated as responsible adults. All staff are readily accessible to respond to requests for assistance from service users. A key-worker system does not operate as this is not considered to be a helpful arrangement by the management. Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 1X3 Key findings/Evidence Standard met? All service users are registered with one local GP surgery where the doctors have a specific interest in the relevant client group. In view of the short-term nature of placements such an arrangement is acceptable. The home ensures that service users have access to all relevant healthcare facilities, including specialist outpatients appointments and visits to dentists. Service users are accompanied to appointments where necessary. The homes accident book was satisfactorily maintained.Weymouth Aftercare CentrePage 30 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? The inspector examined the homes medication storage and recording. Medication is kept in a small room off the kitchen and keys are kept nearby in private staff quarters which can be accessed by all staff administering medication. The home is currently retaining medication for 7 service users and records pertaining to these individuals were well recorded. Other records examined included medicines received and disposed of. They were sufficiently detailed and adequately maintained. The home obtains the Pharmacists stamp to agree what medication was returned to them for disposal. Four staff are attending a 12 week course on Medicines Administration. The homes policy and procedure on medication has been updated in accordance with a requirement made as a result of the last inspection. It now makes reference to receipt and disposal of medication and reference to service users who self-medicate. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 3 Key findings/Evidence Standard met? In view of the relative youth of the service users at the home such an occurrence is an unlikely event. The home has a policy and procedure for staff to follow in the event of a death occurring at Weymouth Aftercare Centre. The admission documentation takes into account the service users religious beliefs.Weymouth Aftercare CentrePage 31 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X X 3 Key findings/Evidence Standard met? The home now has a complaints log and no complaints had been made since the last inspection. Mr Felgate stated that concerns are voiced in the community group meetings and staff act appropriately. A requirement that the record be checked and signed by the registered provider at least every 3 months has now been achieved. The homes complaint procedure was adequate and contained in the terms and conditions of residence document, it includes the advice that a complainant may make direct representations to the Commission for Social Care Inspection.Weymouth Aftercare CentrePage 32 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX2 Key findings/Evidence Standard met? There have been no reported incidents of suspected abuse. With the spirit of openness which prevails in the home and the informality in the relationships between staff and service users this is not an environment in which abuse is likely to prosper. Mr. Felgate has produced an Adult Protection policy and procedure, although it would benefit from a clearer definition of what Adult Protection means. A Whistle Blowing policy and a policy on handling aggression is in place at the home and staff have had in ­ house training from Mr. Felgate on the issue of restraint. For recommendation see YA23Weymouth Aftercare CentrePage 33 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? The home is located within walking distance of Weymouth town centre where there are a range of amenities and facilities. The property has a pleasant garden and casual sitting area (partially enclosed) to the rear of the building. A ground floor rear extension has been in the early stages of construction for several years. Mr Felgate informed the inspector at the last inspection that he made the decision to continue with the original plan of a single storey extension to provide an extended office, a quiet room, and an extended dinning room to offer a larger communal space with access to the garden area. Mr Felgate further stated in April that a meeting with the builder was scheduled for early in May. He agreed to inform the Commission for Social Care Inspection of the discussion and notify any alteration/change to the property. He failed to do this, so the recommendation for the registered provider to produce a realistic timetable for completing the building work at the home, is therefore repeated on this occasion. The home benefits from a planned programme of re-decoration, renewals and repairs and maintenance records were available for inspection. For recommendation see YA24Weymouth Aftercare CentrePage 34 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite NO NO YES 2 X 6 2 X 2X X 4 22 Key findings/Evidence Standard met? There is a predominance of shared bedrooms. The registered providers view is that such an arrangement accords with the homes philosophy and aims and objectives. In accordance with a recommendation first made in 2002, shared bedrooms are currently being fitted with suitable screening to ensure a degree of privacy for the occupants. The inspector advised the registered provider to purchase free - standing screens for the three rooms with sloping ceilings. The largest shared room has a third bed (and accompanying furniture). This bed is used if overnight stays are required for prospective service users attending for assessment. The inspector spoke with the occupants of this room who had no problem with the arrangement and stated that their permission is always sought before a prospective service user is offered overnight accommodation. The homes statement of purpose states the number and size of bedrooms at the home. For recommendation see YA25. Weymouth Aftercare Centre Page 35 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? Service users bedrooms were personalised to varying degrees. The registered providers attempts at upgrading Weymouth Aftercare Centre over the past year are commendable. Each bedroom now has had new bedding and curtains, one bedroom has new furniture and three bedrooms have been redecorated. One bedroom has new carpet and the second floor bathroom has new flooring. The lounge and dinning room have also been decorated recently. All bedrooms had radiators which have been fitted with thermostatic control valves to allow the occupant to control the temperature in his room. Each bedroom now has at least 2 double sockets. As windows in rooms on the first and second floors are not fitted with restrictors, a risk assessment is completed to this effect. Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? The home has 5 toilets and 2 bathrooms. The facilities were found to be clean and fit for the purpose. On the day of inspection a plumber was fitting an additional wash hand basin to the bedroom containing three beds. The number of toilets, baths/showers, wash hand basins and en suite facilities at the home are now included in the statement of purpose/service users guide in accordance with a requirement made as a result of the last inspection. Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? There are a total of three communal rooms, including a dining room which has recently acquired a computer for service users, a library area which is designated as the smoking area and a lounge. One room can be set aside for service users to receive visitors in private, although it is not specifically for this purpose. Two of the rooms are suitable for group meetings. There is a payphone in the hallway for general use. The office telephone is used for private calls to such people as Social Workers and Probation Officers.Weymouth Aftercare CentrePage 36 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 9 Key findings/Evidence Standard met? All service users are able bodied and therefore there is no need for physical adaptations. The home would not be suitable for a person with a physical disability.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The home was found to be clean. The service users clean their bedrooms and most communal areas, under the overall supervision of the staff. There are no laundry facilities on the premises. Information on laundry arrangements should feature in the homes statement of purpose. Service users are provided with money to do their personal laundry in a nearby laundrette, whilst bed linen is cleaned via an external laundry service. This arrangement is in accordance with the homes philosophy of assisting the recovery process and encouraging service users to make use of community resources. The home has a comprehensive infection control policy/procedure which describes in general terms appropriate preventative and reactive measures. In view of the medical history of some service users, the home adopts precautionary infection control measures as part of the daily routine and all staff have undergone in ­ house training.Weymouth Aftercare CentrePage 37 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 3 Key findings/Evidence Standard met? Staff demonstrated that they had a clear understanding of their role and of the aims of the home. Suitable therapeutic relationships are established between staff and service users and there is a good level of empathy and understanding of issues relating to substance abuse. All job descriptions examined were appropriate.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? Staff have relevant experience and those involved in counselling either have a qualification or are working towards achieving this. Staff have other qualifications relating to health and safety and to running a care home. One member of staff has NVQ 2 qualification and commences NVQ 3 next month. Mr Felgate stated that a further member of staff has almost completed NVQ 2 and two members of staff are likely to commence NVQ level 2 training in January 2005. Mr Felgate was reminded of the need for 50 of care staff to be trained at NVQ Level 2. Qualifications must be gained by 2005.Weymouth Aftercare CentrePage 38 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X 14 240 1 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X 246 Nursing X X XXX2 Key findings/Evidence Standard met? In addition to the registered providers (who work part time hours) the home has a senior counsellor, 2 counsellors, 2 support workers one of whom assists with cooking when the main cook is away. The staff group are effective with the majority having been in post for several years. A weekly record of staffing arrangements is maintained. Staffing arrangements are made according to the assessed needs of the service users; currently, dependency levels are not calculated in accordance with Department of Health guidance. A requirement was made as a result of the last inspection for Mr Felgate to purchase the Residential Forum Calculator from the Social Care Association and calculate the total number of hours needed in accordance with the assessed dependency levels of service users, with the total number of staff hours currently provided at the home. This has not been achieved so the requirement is repeated on this occasion. Mr Felgate should ensure that the Calculator is purchased and used by the time specified in this report. Staff meet on a daily basis and more recently a meeting has been introduced on the last Thursday of the month. However, this meeting is not recorded or actioned so for the fourth time, this recommendation is repeated. The registered providers must ensure that staff meetings take place at least 6 times a year and that these meetings are recorded and actioned. For requirement see Regulation 18(1)(a) and recommendation YA33Weymouth Aftercare CentrePage 39 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? Written evidence suggests that the homes recruitment policy and procedure is slowly improved with each inspection. Mr Felgate acknowledged that further work was required in order to fully meet this standard. New contracts and terms and conditions of employment are still to be introduced. As on the last occasion, the inspector advised that a minimum of 3 months probationary period and at least 5 days training (pro-rata) be added. Mr Felgate reported that no new appointments had been made since April 2002. As the majority of staff members have been in post for several years, their application form and record of references may not have been retained. Police checks via the Criminal Records Bureau on all existing staff members have been applied for but given the length of time it is taking for their return, the registered provider should chase them. Given the short-term nature of service user placements at the home it would not be appropriate to involve them formally in the staff recruitment procedure. The registered providers must have a robust recruitment procedure to include volunteers. The procedure for future staff (and volunteers) should involve a written application form, formal interview, two written references and a satisfactory check from the criminal record bureau. Each member of staff must have in their personal file, a recent photograph and documentary evidence of their qualifications. They should also have a formal contract stating the terms and conditions of their employment and be given a copy of the homes disciplinary and grievance procedures and the General Social Care Council code of practice. Since the last inspection Mr. Felgate has purchased copies of the General Social Care Council code of practice which relates to standards of conduct in the caring profession. All staff are expected to adhere to these standards. For requirements see Regulation 19(1) and 19 Schedule 2. Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? Mr. Felgate in conjunction with Weymouth College Assessment Team has conducted a training needs analysis for the team. Staff have personal training files that were very well maintained with certificates in place.Weymouth Aftercare CentrePage 40 Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 1 Key findings/Evidence Standard met? Mr Felgate was unable to evidence that formal staff supervision was taking place for all staff. Three members of staff had a supervision record, however, three did not. Mr Felgate has been particularly slow in his attempts to meet this standard which was first brought to his attention in December 2002. He stated that until now supervision has been with external counsellors to assist staff with their professional practice and development. The registered providers have been paying for this facility. In order to prevent enforcement action being taken, the registered providers must ensure that staff supervision takes place at least 6 times a year within the time scale specified in this report. A record must be maintained and the supervisee must be given a copy. The sessions should address the individuals training needs and personal development plan. The registered providers should refer to the National Minimum Standards ­ Care Homes for Adults, for guidance. Staff annual appraisals are ongoing and were available for inspection. For requirement see Regulation 18(2)Weymouth Aftercare CentrePage 41 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO2 Key findings/Evidence Standard met? The registered providers, Mr and Mrs Felgate, have several years experience of managing a care home. Neither has obtained NVQ level 4 in management and care but it is their intention for one of them to achieve it prior to 2005. In addition to a counselling qualification, Mr Felgate has a certificate in education. Dominic Castle, the senior counsellor also assists with managerial tasks at the home. The registered provider should given consideration to the appointment of a registered manager for the home. For recommendation see YA37 Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The structure of the home lends itself to an open style of management. The atmosphere in the home on the day of the inspection was positive and productive. The inspector witnessed staff treating service users with respect throughout the day. Service users spoken with considered that staff were approachable and they felt comfortable about expressing views and making suggestions. The main vehicle for instigating change and development is through the various group settings and meetings which take place on most days.Weymouth Aftercare CentrePage 42 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 2 Key findings/Evidence Standard met? The last two inspections have highlighted the need for the home to have a quality assurance system. At the last inspection Mr Felgate evidenced that he had started to address this matter with the issuing of a feedback form to service users once a month. However, they have not been used regularly and neither has a similar form specifically designed for others eg. Relatives and Care Managers etc. The registered providers must introduce a formalised system to monitor quality assurance at the home within the time scale specified in this report. Failure to do so may result in enforcement action being taken. The inspector sought comments from the service users and Care Managers for this inspection. To date there has been no responses from Care Managers. The inspector spoke with all service users as a group. They made positive comments about the care, facilities and services at Weymouth After Care Centre and stated that the treatment on offer at the home was excellent and that staff were very caring and knowledgable. For requirement see Regulation 24 Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? The process of monitoring, reviewing and amending all policies, procedures, codes of practice and records in a formalised way to include signature and date is ongoing at the home. Staff and service users have access to this documentation.Weymouth Aftercare CentrePage 43 Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 1 Key findings/Evidence Standard met ? Service users are able to access their records at any time and are fully aware of what is written in their file. Individual records are secure in the office. The inspector examined fire records and found them to be unsatisfactory.A fire drill was overdue and there was no evidence of fire training for staff having taken place since the last inspection. Mr Felgate stated that training had taken place but the record could not be located whilst the inspector was on the premises. Similar findings have been found in the past. An immediate requirement was issued to Mr Felgate giving him 7 days to evidence that a fire drill and fire training for staff has taken place. The registered providers must ensure that all staff receive training every 6 months (every 3 months for night staff) and that the content of the fire training session is recorded. The record must evidence a staff signature to verify who attended the training. For requirement see Regulation 23(4) Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? Measures and systems are in place to cover most aspects of health and safety, including the regular servicing of most of the installations and equipment and staff training. The homes electrical and gas certificates were valid as was the portable appliance test certificate. There have been no reportable accidents, injuries, illness or communicable disease or the death of a service user at Weymouth After Care since the last inspection. Water temperatures at the home are still not recorded despite a recommendation being made at the last three inspections. A record must be kept, the boiler must be 60 degrees to prevent Legionella disease and around 43 degrees at the outlets. The registered provider is advised to either complete risk assessments for each service user in respect of water temperatures if the current temperature exceeds 43 degrees, or fit regulator valves to hot water taps to ensure that the water is around 43 degrees. Caution Hot Water stickers have been fixed near wash hand basins. The recommendation is repeated on this occasion. The registered providers should provide evidence that the home has had a water test for Legionella Disease. The home has been inspected by an Environmental Health Officer since the last inspection. Four recommendations were made two of which have been addressed. Mr Felgate stated that in order to comply with the other two recommendations parts have been ordered from Canada. For recommendations see YA42Weymouth Aftercare CentrePage 44 Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 1 Key findings/Evidence Standard met ? The registered provider reported that records of all business transactions were held and that an accountant conducted an annual audit of the accounts. To date a business and financial plan has not been produced despite it being made a requirement in December 2002 and repeated in May and October 2003 and April 2004. Mr Felgate stated that he held a business meeting in May and a plan emerged from discussions at this meeting. He stated that evidence of this was held at his home. He was advised to forward a copy to the Commission for Social Care Inspection within the time scale specified in this report. Failure to do so may result in enforcement action being taken. Suitable insurance and public liability arrangements is in place and documentation examined by the inspector on this occasion. For requirement see Regulation 25Weymouth Aftercare CentrePage 45 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager DateJulia MooneySignature Signature SignaturePublic reports It should be noted that all CSCI inspection reports are public documents.Weymouth Aftercare CentrePage 46 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 14th September 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Weymouth Aftercare Centre Page 47 Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 29th October 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action plan YESOther: enter details here Weymouth Aftercare CentrePage 48 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 ................................................................ confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 ............................................................. am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Weymouth Aftercare CentrePage 49 Weymouth Aftercare Centre / 14th September 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000026891.V183555.R01© This report may only be used in its entirety. 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