Inspection on 21/04/04 for Weymouth AfterCare Centre

Care Homes For Adults (18 ­ 65)Weymouth Aftercare CentreCarlton House 9 Carlton Road North Weymouth Dorset DT4 7PXAnnounced Inspection21st April 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 14/10/03 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 321st April 2004 10:00 am Julia MooneyID Code072711Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at Mr Trevor Felgate the time of inspectionWeymouth Aftercare CentrePage 2 CONTENTSIntroduction to Report and Inspection Inspection visits Description of service Part A: Summary of Inspection Findings Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods Used & Findings The Standards. 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: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration ( if applicable) Lay Assessors summary (where 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 National Care Standards Commission (NCSC) 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 NCSC in respect of Weymouth Aftercare Centre. The inspection findings relate to the National Minimum Standards (NMS) for Care Home 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 NCSC 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 · Report of the Lay Assessor (where relevant) · 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 and the Children Act 1989 as amended. 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. The home has been inspected for compliance with National Minimum Standards under the Care Standards Act 2000 since April 2002, and since then a requirement has been made at each inspection visit for Mr Felgate to produce a Statement of Purpose/Service Users Guide. In accordance with this requirement, Mr Felgate has clearly worked hard to produce a very comprehensive Statement of Purpose/Service Users Guide. It contains relevant information about the home, including the aims, objectives facilities and services. However, minor alterations and a little additional information is required in order for the document to meet statutory requirements. 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 referral form clearly states the outcome of this assessment. 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 4 - 6 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. However, it does meet the standard to produce a costed contract between the home and the service user. The registered providers must produce a written and costed contract/statement of terms and conditions between the home and the service user within the time scale stated in this report. Individual Needs & Choices (Standards 6-10) 3 of the 5 standards assessed were met. New care plans have recently been introduced for each service user. 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. Although the three care plans examined by the inspector referenced attendance at college, the plan has no specific sections to assess education/training, voluntary work placements or the family/social support of that individual. As the majority of service users are involved in education/training and voluntary work, it would be beneficial to have a section in the care plan in order to detail the content of course service user is attending, where and when he Weymouth Aftercare Centre Page 6 attends the course, or voluntary placement etc. The three care plans were signed and dated by the staff member and the service user. However, the review date was not completed on any of the care plans examined. 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. However, it has not yet been used. Mr Felgate was urged by the inspector to introduce it immediately. The home works with service users in a particular way. Daily group meetings are primarily therapeutic in nature, but may give rise to discussions about the structure of the recovery programme. Service users complete a weekly self assessment document. These assessments are shared with their peers in group discussions and a personal review takes place once a month. The principle of self-determination is intrinsic to the recovery programme. Service users retain responsibility for their own progress. Service users hold monthly household meetings to discuss issues relating to the running of the home. In accordance with a requirement first made in 2002, Mr Felgate has introduced risk assessments for each service user. They form part of the care plan. The inspector examined three risk assessments and noted that staff sign the document but service users did not. 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. The assessments would benefit from additional boxes for history of aggression/violence and restrictions imposed by the Courts under the Criminal Justice Act and the homes Statement of Purpose and Service Users Guide should make reference to Orders and restrictions imposed by the Courts. 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) 4 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. Activities include life and social skills programmes, basic numeracy, literacy and computer skills. Use is made of Weymouth College to assist in the running of relevant programmes. The inspector found reference to service users being involved in education in individual plans, although there was no specific section in care plans for education/training. In addition many service users choose to undertake voluntary work placements. No reference to this could be found in individual care 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 Longleat House, the Fleet Air Museum over the Easter weekend and Portland earlier this month. 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 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. The registered providers must ensure that this forms part of the care plan for each service user in order to meet this standard. 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. The inspector could not find reference to the rationale for this in the homes new Statement of Purpose/Service Users Guide. The recommendation is therefore 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) 2 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. The home is currently retaining medication for 4 service users. Records pertaining to medicines received were adequately maintained. There is now a disposal record at the home detailing what medication has been returned to the Pharmacy. It would be better practice if the home obtained a Pharmacists signature to agree what was returned. 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. However, there was no reference to service users who selfmedicate so a requirement has been made on this occasion. In view of the relative youth of the service users at the home such an occurrence is an unlikely event. In accordance with a recommendation first made in 2002, the home now has a policy and procedure for staff to follow in the event of a death occurring at Weymouth Aftercare Centre. The inspector discussed the procedure with Mr Felgate and as a result, Mr Felgate wishes to add a little more information. The recommendation is therefore repeated on this occasion. 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 not been achieved so it is repeated on this occasion and should be addressed within the time scale stated in this report. 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. The registered provider has recently decided to continue with the original plan of a single storey extension that will provide an extended office, a quiet room, an extended dinning room which will provide a large communal space with access to the garden area. Mr Felgate stated that a meeting with the builder is scheduled for early in May. Mr. Felgate is reminded of the need to notify the Commission for Social Care Inspection of any alteration/change to the property. In accordance with a recommendation made as a result of the last inspection, the home now 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 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 registered providers attempts at upgrading Weymouth Aftercare Centre since the last inspection 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. Decorating has also commenced on the ground floor with the lounge and dining room. Particularly impressive was the stripped pine flooring in the lounge which was only completed the day before the inspection. All bedrooms had radiators which have now been fitted with thermostatic control valves to allow the occupant to control the temperature in his room. This was identified during the homes first inspection under the Care Standards Act in December 2002 and a requirement made. 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 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. 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 Weymouth Aftercare Centre Page 9 service users to make use of community resources. Staffing (Standards 31-36) 1 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. 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. Mr Felgate must obtain a copy of the Residential Forum Calculator 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. 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 now maintained. 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. The registered providers must ensure that staff meetings take place at least 6 times a year and that these meetings are recorded and actioned. The recommendation is therefore repeated on this occasion. The homes recruitment policy and procedure has improved since the last inspection and the three staff files examined contained more information than on previous occasions. Three members of staff had a copy of their passport and birth certificates. Mr Felgate acknowledged that further work was required in order to fully meet this standard, he stated that new staff files should be completed by 1st May. New contracts and terms and conditions of employment are going to be introduced. They were examined by the inspector who advised that a minimum of 3 months probationary period and at least 5 days training (prorata) 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. 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 is about to address the requirement first made in December 2002 and repeated in May and October 2003, to introduce formal arrangements for staff supervision. Supervision until now has been with external counsellors to assist staff with their professional practice and development. The registered providers have been paying for this facility. The registered providers must ensure that staff supervision takes place at least 6 times a year within the time scale specified in this report. Failure to do so may result in enforcement action being taken. 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. Conduct and Management of the Home (Standards 37-43) 1 of the 7 standards assessed were met. Weymouth Aftercare Centre Page 10 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. Recently Mr Felgate has begun to address this matter by introducing a feedback form which is issued to service users once a month. The inspector looked at the feedback forms. To date three out of ten service users have responded and there were no notable comments made. Mr Felgate showed the inspector a similar form specifically designed for others eg. Relatives and Care Managers but it had yet to be issued. The inspector sought comments from the service users and General Practitioner for this inspection. To date there has been no response from the General Practitioner. All current service users completed the cards for comments see Standard 39. 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. Mandatory fire training for staff is scheduled for May 2004. However, records evidenced that three staff members did not attend the last fire training session and were not given a one ­ to-one session to compensate. 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 evidenced that staff who attended the training signed to this effect. 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. The testing of electrical equipment has been scheduled for May 2004. Water temperatures at the home are still not recorded despite a recommendation being made at the last two 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 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. Mr. Felgate stated that a business meeting is planned for the first week in May and a plan should materialise from discussions at this meeting. Mr Felgate is urged to address this issue 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 the documentation was examined by the inspector on this occasion.Weymouth Aftercare CentrePage 11 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. No. Regulation Standard Required actions Timescale for action 1 5 YA5 Each service user must have a written and costed contract/statement of terms and conditions with the home. The service users plan must be kept under review and where appropriate, must be revised. 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. 13 YA20 The homes medication policy and procedure must make a reference to service users who self medicate and include the need for a risk assessment for such individuals. Service users individual plans shall make reference to education and/or voluntary placements. Service users individual plans shall include details of family links and significant friendships and level of contact service user wants. 31/03/04 31/03/04215(2)YA631/03/04313(4)YA931/03/04416(2)YA1231/03/0416(2)YA1531/03/04Weymouth Aftercare CentrePage 12 517(2)YA22The homes complaint record must be checked by the registered provider at least every three months All staff should have a job description which reflects their duties and which (in the case of care staff) are linked to achieving service users goals as set out in the service users plans. All future staff appointments should be made on the basis of a minimum three month probationary period31/03/0417(2) Schedule 4YA3131/03/04618(2)YA36The registered person must ensure that 31/03/04 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 plans719(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. A copy of each staff members birth certificate and passport must be retained at the home. A recent photograph must also be in respective files. Original date for compliance was 31/03/0331/03/0419 Schedule 2YA3431/03/0419 Schedule 2 8 25YA34A police check on all existing staff members must be conducted via the criminal record bureau Original date for compliance was 31/03/0331/03/04YA43The home should have an annual business and financial plan available for inspection.31/03/04Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements.Weymouth Aftercare CentrePage 13 RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 2 YA16 YA20 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 All staff should receive appropriate training with regards to basic knowledge of how medicines are used and how to recognise and deal with problems in use, and the principles behind all aspects of the homes policy on medicines handling and records. 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. 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 registered providers should have the responsibility for signing, dating, reviewing, monitoring and amending all policies, procedures, codes of practice and records at Weymouth Aftercare Centre. The home should regularly record water temperatures and consider fitting temperature control valves to hot water taps in the bathrooms at Weymouth Aftercare Centre3 4 5 6YA24 YA32 YA33 YA377YA408YA42CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). NONEMET (YES/NO)Weymouth Aftercare CentrePage 14 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 and recommendations 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, the National Minimum Standards and the relevant sections of the Childrens Act. The Registered Provider(s) is/are required to comply within the given time scales. 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. 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 The service users plan must be kept under review and where appropriate, must be revised. Original date for compliance was 31/03/0414YA130/08/0425YA530/08/04315(2)YA630/08/04Weymouth Aftercare CentrePage 15 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 The homes medication policy and procedure must make a reference to service users who self medicate and include the need for a risk assessment for such individuals. Original date for compliance was 31/03/04 Service users individual plans shall make reference to education and/or voluntary placements. Original date for compliance was 31/03/04 Service 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 homes complaint record must be checked by the registered provider at least every three months. Original date for compliance was 31/03/04413(4)YA930/08/0413YA2030/08/04516(2)YA1230/08/0416(2)YA1530/08/04617(2)YA2230/08/04Weymouth Aftercare CentrePage 16 17(2) Schedule 4YA31All staff should have a job description which reflects their duties and which (in the case of care staff) are linked to achieving service users goals as set out in the service users plans. All future staff appointments should be made on the basis of a minimum three month probationary period. Original date for compliance was 31/03/0430/08/0417(2) Schedule 4(6)(f) YA34The registered providers must purchase copies of the General Social Care Council code of practice which relates to standards of conduct in the caring profession. All staff should be given a copy and be expected to adhere to these standards. 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. The registered person must ensure that persons working at the care home have regular supervision meetings at least six times a year.30/08/04718(1)(a)YA3230/08/0418(2)YA36Staff shall have an annual appraisal with their senior manager to review performance against job descriptions and agree career development plans. Original date for compliance was 31/03/04 The 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. Original date for compliance was 31/03/0430/08/04819(1)YA3430/08/04Weymouth Aftercare CentrePage 17 19 Schedule 2YA34A copy of each staff members birth certificate and passport must be retained at the home. A recent photograph must also be in respective 30/08/04 files. Original date for compliance was 31/03/0319 Schedule 2YA34A police check on all existing staff members must be conducted via the criminal record bureau Original date for compliance was 31/03/03 The registered providers must further develop the quality assurance system recently introduced at the home to include surveys from relevant professionals and relatives. The outcome from all surveys should indicate success in achieving the homes aims and objectives and inform future planning. The registered provider must ensure that all staff receive fire training every 6 months (3 months for night staff) and that the content of the training is recorded. The home should have an annual business and financial plan available for inspection. Original date for compliance was 31/03/0430/08/04924YA3930/08/041023(4)YA4130/08/041125YA4330/08/04RECOMMENDATIONS 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) No. Refer to Good Practice Recommendations Standard * 1 YA16 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 It is recommended that when medication is returned to the Pharmacy, staff obtain the Pharmacists signature to confirm medication has been disposed of. All staff should receive appropriate training with regards to basic knowledge of how medicines are used and how to recognise and deal with problems in use, and the principles behind all aspects of the homes policy on medicines handling and records. Page 182YA203YA20Weymouth Aftercare Centre 4 5 6 7YA21 YA23 YA24 YA25The registered provider should finalise the procedure for staff to follow in the event of a death occurring at the home. 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 30/08/04. 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. 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 registered providers should have the responsibility for signing, dating, reviewing, monitoring and amending all policies, procedures, codes of practice and records at Weymouth Aftercare Centre. The home should regularly record water temperatures and consider fitting temperature control valves to hot water taps in the bathrooms at Weymouth Aftercare Centre8YA329YA3310YA3711YA4012YA42* Note: You may refer to the rel evant 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 Weymouth Aftercare Centre YES YES YES YES YES YES NO NO YES NO YES Page 19 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: 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)NO YES YES YES NO YES YES NO YES 6 X X YES NA YES YES 6 X 21/04/04 10:00 6The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards 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, 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? The home has been inspected for compliance with National Minimum Standards under the Care Standards Act 2000 since April 2002, and since then a requirement has been made at each inspection visit for Mr Felgate to produce a Statement of Purpose/Service Users Guide. In accordance with this requirement, Mr Felgate has clearly worked hard to produce a very comprehensive Statement of Purpose/Service Users Guide. It contains relevant information about the home, including the aims, objectives facilities and services. However, minor alterations and a little additional information is required in order for the document to meet statutory requirements. These details have been discussed with Mr Felgate. 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 4 - 6 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. However, it does meet the standard to produce a costed contract between the home and the service user. The registered providers must produce a written and costed contract/statement of terms and conditions between the home and the service user within the time scale stated 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. 2 Key findings/Evidence Standard met? New care plans have recently been introduced for each service user. 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. Although the three care plans examined by the inspector referenced attendance at college, the plan has no specific sections to assess education/training, voluntary work placements or the family/social support of that individual. As the majority of service users are involved in education/training and voluntary work, it would be beneficial to have a section in the care plan in order to detail the content of course service user is attending, where and when he attends the course, or voluntary placement etc. (For requirement see Standard 12). The three care plans were signed and dated by the staff member and the service user. However, the review date was not completed on any of the care plans examined. 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. However, it has not yet been used. Mr Felgate was urged by the inspector to introduce it immediately. Mr Felgate stated that each service user can expect at least one care plan review during his stay at Weymouth Aftercare. 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. Reviews which involve all relevant parties (including the representative from the referring agency) are conducted and written summaries are provided by the home on the service users departure or at other significant intervals. For requirement see Regulation 15(2) Weymouth Aftercare Centre Page 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 inspector examined a file of a service user subject to such a condition. It detailed the condition and staff had diligently completed the record in accordance. 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? In accordance with a requirement first made in 2002, Mr Felgate has introduced risk assessments for each service user. They form part of the care plan. The inspector examined three risk assessments and noted that staff sign the document but service users did not. 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. The assessments would benefit from additional boxes for history of aggression/violence and restrictions imposed by the Courts under the Criminal Justice Act eg. does the service user have a tagging device? If so, the time of curfew should be added to his risk assessment. Is the service user subject to a Drug Testing and Treatment Order? If so, the frequency of urine tests should be added to his risk assessment with details of who imposed the order and where to send urine test results etc. The homes Statement of Purpose and Service Users Guide should make reference to Orders and restrictions imposed by the Courts under the Criminal Justice Act. 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. In accordance with a recommendation made as a result of the last inspection, this statement now 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 2 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. Activities include life and social skills programmes, basic numeracy, literacy and computer skills. Use is made of Weymouth College to assist in the running of relevant programmes. The inspector found reference to service users being involved in education in individual plans, although there was no specific section in care plans for education/training. In addition many service users choose to undertake voluntary work placements. No reference to this could be found in individual care plans. For requirement see Regulation 16(2).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. 3 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 Longleat House, the Fleet Air Museum over the Easter weekend and Portland earlier this month. Staff are on duty at all times to assist service users, where needed. 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. 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. The registered providers must ensure that this forms part of the care plan for each service user in order to meet this standard. 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. The inspector could not find reference to the rationale for this in the homes new Statement of Purpose/Service Users Guide. Mr Felgate said it was an oversight and that he would add this information to the document. The recommendation is therefore 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 procedure 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. 2 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 4 service users. Records pertaining to medicines received were adequately maintained. There is now a disposal record at the home detailing what medication has been returned to the Pharmacy. It would be better practice if the home obtained a Pharmacists signature to agree what was returned. Up to four staff are about to commence 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. However, there was no reference to service users who self-medicate. For requirement see Regulation 13 and two recommendations YA20.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. 2 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. In accordance with a recommendation first made in 2002, the home now has a policy and procedure for staff to follow in the event of a death occurring at Weymouth Aftercare Centre. The inspector discussed the procedure with Mr Felgate and as a result, Mr Felgate wishes to add a little more information. The recommendation is therefore repeated on this occasion. The admission documentation takes into account the service users religious beliefs. For recommendation see YA21Weymouth 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 times-scales 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 NCSC Percentage of complaints responded to within 28 days X X X X X X X 2 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 not been achieved so it is repeated on this occasion and should be addressed within the time scale stated in this report. 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. For requirement see Regulation 17(2)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 YESX3 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 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. 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. The registered provider has recently decided to continue with the original plan of a single storey extension that will provide an extended office, a quiet room, an extended dinning room which will provide a large communal space with access to the garden area. Mr Felgate stated that a meeting with the builder is scheduled for early in May. Mr. Felgate is reminded of the need to notify the Commission for Social Care Inspection of any alteration/change to the property. In accordance with a recommendation made as a result of the last inspection, the home now 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 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. One of the bedrooms on the first floor is particularly small. The homes statement of purpose now states the number and size of bedrooms at the home in accordance with a requirement made as a result of the last inspection. 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 since the last inspection 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. Decorating has also commenced on the ground floor with the lounge and dinning room. Particularly impressive was the stripped pine flooring in the lounge which was only completed the day before the inspection. All bedrooms had radiators which have now been fitted with thermostatic control valves to allow the occupant to control the temperature in his room. This was identified during the homes first inspection under the Care Standards Act in December 2002 and a requirement made. 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. 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 inspection, 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. 2 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. 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. For requirement see Regulation 17(2) Schedule 4Weymouth Aftercare CentrePage 38 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. 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? 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. Mr Felgate should 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. 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. For requirement see Regulation 18(1)(a) and recommendation YA32Weymouth Aftercare CentrePage 39 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. 2 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 now maintained. 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. The registered providers must ensure that staff meetings take place at least 6 times a year and that these meetings are recorded and actioned. The recommendation is therefore repeated on this occasion. For recommendation see YA33 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? The homes recruitment policy and procedure has improved since the last inspection and the three staff files examined contained more information than on previous occasions. Three members of staff had a copy of their passport and birth certificates. Mr Felgate acknowledged that further work was required in order to fully meet this standard, he stated that new staff files should be completed by 1st May. New contracts and terms and conditions of employment are going to be introduced. They were examined by the inspector who advised that a minimum of 3 months probationary period and at least 5 days training (prorata) 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. 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 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, copy of birth certificate, copy of current passport 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. Mr. Felgate must purchase copies of the General Social Care Council code of practice which relates to standards of conduct in the caring profession. All staff should be given a copy and be expected to adhere to these standards. For requirements see Regulation 17(2) Schedule 4(6)(f), 19(1) and 19 Schedule 2.Weymouth Aftercare CentrePage 40 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.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 is about to address the requirement first made in December 2002 and repeated in May and October 2003, to introduce formal arrangements for staff supervision. Supervision until now has been with external counsellors to assist staff with their professional practice and development. The registered providers have been paying for this facility. The registered providers must ensure that staff supervision takes place at least 6 times a year within the time scale specified in this report. Failure to do so may result in enforcement action being taken. 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. Staff annual appraisals have commenced since the last inspection and two were examined by the inspector. 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 or equivalent. 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 daysWeymouth 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. Recently Mr Felgate has begun to address this matter by introducing a feedback form which is issued to service users once a month. The inspector looked at the feedback forms. To date three out of ten service users have responded and there were no notable comments made. Mr Felgate showed the inspector a similar form specifically designed for others eg. Relatives and Care Managers but it had yet to be issued. The inspector sought comments from the service users and General Practitioner for this inspection. To date there has been no response from the General Practitioner. All current service users completed the cards and comments included: I am happy here. I find my time here hard in written work but accept that its for my own good. In my free time I enjoy myself. I think the staff could provide more group activities. I think the house could spend more money on furnishing and décor but I think they try as hard as funds that are available. I find it hard that we either wash our clothes by hand or have to take them to the launderette which costs approximately £6 having to use much of our tight budget. It would be nice to have a machine to use on the premises. Other than that I find the staff extremely helpful and the food fantastic. The staff have been kind and supportive in extra ways. They have helped me with clothing issues. Carlton House has fully supported me in all areas. I can only thank the staff for their advice and care. For requirement see Regulation 24Standards 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 Younger Adults. 2 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. For recommendation see YA40Weymouth 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. 2 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. Mandatory fire training for staff is scheduled for May 2004. However, records evidenced that three staff members did not attend the last fire training session and were not given a one ­ to-one session to compensate. 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 evidenced that staff who attended the training signed to this effect. 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. The testing of electrical equipment has been scheduled for May 2004. There have been no reportable accidents, injuries, illness or communicable disease or the death of a service user at Weymouth Aftercare since the last inspection. Water temperatures at the home are still not recorded despite a recommendation being made at the last two 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. For recommendation see YA42 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. Mr. Felgate stated that a business meeting is planned for the first week in May and a plan should materialise from discussions at this meeting. Mr Felgate is urged to address this issue 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 25 Weymouth Aftercare Centre Page 44 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager DateJulia MooneySignature Signature Signature14/06/04Weymouth Aftercare CentrePage 45 PART D(where applicable) Not applicable.LAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.Weymouth Aftercare CentrePage 46 PART EE.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 21st April 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the NCSC in response to provider comments: Weymouth Aftercare Centre Page 47 Amendments to the report were necessaryNOComments 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 accurateNONote: 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. E.2 Please provide the Commission with a written Action Plan by 11th June 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 publicationYESAction 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 planYESOther: enter details here Weymouth Aftercare CentrePage 48 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I 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 E.3.2 I 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 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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