Inspection on 01/02/07 for Wings

This inspection was carried out on 1st February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wings 06/04/06

Wings 23/11/05

Wings 18/08/05

Similar services:

Chesham House

Argyll House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

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

CARE HOME ADULTS 18-65 Wings 17 The Grove Beck Row Mildenhall Suffolk IP28 8DP Lead Inspector Deborah Kerr Unannounced Inspection 1st February 2007 09:00 Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wings Address 17 The Grove Beck Row Mildenhall Suffolk IP28 8DP 01638 583934 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Compass Care Limited Post Vacant Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No person falling within the category of MD, Mental Disorder excluding Learning Disability or Dementia may be admitted into the home unless that person also falls within the category LD, Learning Disability is Dual Disability. 6th April 2006 Date of last inspection Brief Description of the Service: Wings is registered as a Care Home for 6 younger people with learning disability and mental health needs, and offers placements to individuals with challenging behaviour. The home is situated on a private road in Beck Row, near to Mildenhall air base. The location is semi-rural and transport is provided by the home’s two vehicles to enable service users to access local facilities. Parking is available at the front of the building. The bungalow offers six individual bedrooms, a living room and a dining room. The Managers office is situated at the front of the home. The fenced garden is mainly grass, but has a patio area and vegetable/flower patch maintained by people living in the home. Wings is owned and run by Compass Care. Compass Care is owned by Tracs Ltd. The home has a detailed statement of purpose providing information about the facilities and services provided. The service user guide is in the process of being updated to provide additional information to prospective service users, including the most recent inspection report by the Commission for Social Care Inspection (CSCI). The fees range from £1676.00 to £2237.66 per week. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on a weekday lasting eight hours. This was the second key inspection for the year 2006/7, which focused on the core standards relating to the adults, aged 18-65 and the progress made to address the eleven requirements and three recommendations set at the key inspection in April 2006. The report has been written using accumulated evidence gathered prior to and during the inspection. This included reviewing information provided in the pre inspection questionnaire completed in August 2006, the home’s statement of purpose and service user guide. Additionally, a number of records were reviewed including those relating to service users, staff, training and policies and procedures. Time was spent with five service users, three staff and the new homes’ manager. The organisation’s maintenance person and a service user accompanied the inspector on a tour of the environment. What the service does well: What has improved since the last inspection? Compass Care has invested considerable expenditure to improve the décor and facilities at Wings. The front drive way has been concreted over providing level access for wheelchair users. Inside the home there has been a programme of maintenance including replacing the boilers and refurbishment of the kitchen and laundry. Communal areas, such as the wet room, shower and corridors have been redecorated. However these rooms are looking sterile and would benefit from brighter colours and posters to create a homely and cheerful environment. There are plans in place for refurbishment of the bathroom. Eleven requirements were made at the previous inspection; there has been some progress to address these areas of concern. A copy of the service user’s guide was seen which confirmed the manager was in the process of updating Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 6 and reviewing this information. Service user’s contracts must be signed and dated and agreed by the service user and/or their representative and Tracs care. Information following appointments and visits from health professionals are now being recorded appropriately in service users’ care plans. Records seen confirmed that medication was being administered correctly and in line with the home’s policies and procedures. Repeat requirements have been made for a service user to be assessed by an Occupational Therapist (OT) to ensure that they have the appropriate equipment which meets their needs. The manager confirmed an OT has assessed the service user for a custom made wheelchair and shower/commode chair. The complaints procedure has been reviewed to ensure the concerns of service users and other complainants are listened and responded to. Staff files confirmed that a check against the Protection of Vulnerable Adults (POVA) list is requested when Criminal Record Bureau (CRB) checks are being made for new staff. A review of systems in the home has provided safer practice for storing household cleaning equipment and materials; these are now kept in the laundry, which has been fitted with cupboards and a metal lockable cabinet. What they could do better: The home must be clear about the service they provide and ensure that they can meet the needs of service users before they move into the home. New service users are admitted to the home only on the basis of a full needs assessment by persons competent to do so. They must ensure that staff are fully trained and have the skills to meet the diverse needs of the service users for whom the home is intended. The pre admission statement of the most recent service user had not been fully completed and the information that had been obtained clearly identified that Wings was not a suitable placement. It is essential that the existing service users be consulted on who moves into their home. In the last year there has been a breakdown of placements for three service users, which has caused anxiety to the original service users and staff in the home. The pre inspection questionnaire reflects that two staff have left employment at the home due to being assaulted by a service user. The practice of locking internal doors to the kitchen and laundry to protect the safety of one service user must be reassessed and appropriate measures taken. This is a restrictive physical intervention preventing other services accessing areas of their home. The home has two folders of policies and procedures, which is confusing when looking for guidance. One file contains Tracs care policies and procedures the other contains those relating to the former company of Compass Care. The home’s policies and procedures need to be consolidated in to one file, which reflect the current practice. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 7 Individual plans for service users ‘ageing and dying’ need to be reviewed on a regular basis. One service stated they were unsure if they wanted to be buried or cremated. Service users needs to be provided with information and facts for them to be able to make an informed decision so that at the time of their death their wishes will be respected. Recruitment procedures need to be more robust to safeguard service users from potential risk of abuse. One staff’s file did not contain a completed application form with their career history and two satisfactory references. Staff files confirmed that there was no up to date POVA training. The date set for training in January 2007 had been cancelled. It is recommended that information provided about the home and which relate to service users, such as care plans and contracts are available in formats suitable for their needs. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5, Quality in this outcome area is adequate. Prospective service users cannot currently be confident that the pre admission process will fully identify their needs and aspirations and ensure that the home is a suitable placement. Information about the home needs to be made available in a suitable format for people for whom the home is intended. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service user guide is in the process of being revised. Colour photographs of the exterior and interior of the home and an easy read version of the complaints procedure have been included. Some of the service users spoken with have difficulties reading information. Alternative formats, such as picture bank symbols were discussed with the manager who agreed to look into developing care plans, contracts and other information about the home in a suitable format to meet the needs of all the service users. The service user guide includes a copy of the contract between the home and the service user, which reflects the amount social services or the health authority pay towards their fees and the service users contribution to their rent. The previous inspection report notes that copies of service user’s contracts had been updated to reflect the new owners of Wings. However, two files seen on this occasion did not have completed contracts in place. One had no contract at all; the other service users contract was not signed or dated. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 10 The organisations mission and philosophy states they are able to provide residential service to people with a learning disability and/or mental health impairment, including those who have supervised discharge under the Mental Health Act 1983. However, the manager must be able to demonstrate that they can meet the needs of any service user before they move into the home. The pre admission assessment service user recently admitted was not fully completed and the information that had been obtained clearly identified that Wings was not a suitable placement. The service user has since been served notice to move form Wings. In the last year there has been a breakdown of placements for three service users, which has caused anxiety to the established service users and staff. It is essential that the existing service users are fully consulted on who moves into their home. Prior to any person moving into the home a full needs assessment must be completed by a person competent to do so and staff must receive appropriate training to ensure they have the skills and experience to meet the diverse needs of the service users. For example the manger showed the inspector an assessment undertaken for a prospective service user who has schizophrenia. Staff files reflect that they have undertaken basic mandatory training and (studio 3) management of challenging behaviour. However there has been no recent specific training, which relates to the specific conditions of the service users. The home is currently providing respite for a service user from another Tracs care home. The service user confirmed they had stayed at the home before and knew the other service users quite well. Two of the existing services users spoken with had no concerns about this person staying for respite. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9, Quality in this outcome area is good. Service users can expect to have detailed plans identifying the level of support they need. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans of two service users were inspected to track their care and the level of support they required. These plans would benefit having a photograph of the service user for identification. The care plans consist of six sections, which cover all aspects of the service users personal, healthcare needs and social support. At the front of the care plan is a section written in the words of the service user “ To all staff that help me live at Wings”. This gives a descriptive account of their preferred daily routines in the home and in the community and describes the support they require from staff to achieve this. Where service users are identified as likely to be aggressive or cause harm to themselves or others, reactive management plans have been established. These reflect the triggers and warning signs that the service user is experiencing feelings that cause them to become aggressive or likely to harm themselves. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 12 They describe the interventions staff need to take using distraction techniques to divert the negative behaviour and to provide reassurance to promote the service users self respect and self esteem. Where there are restrictions and limitations these have been identified, discussed with the service user and recorded. Risk assessments had been completed for service users in all aspects of their daily lives. The assessments were comprehensive, detailing the hazards and likely outcomes of each identified risk and identified staff intervention to minimise the risk, whilst supporting the service user to maintain their independence. A service user spoken with confirmed they are supported to manage their own finances. Staff were observed supporting another service user to budget their money to purchase items of furniture and accessories they wanted for their bedroom which was in the process of being decorated. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17, Quality in this outcome area is adequate. Service users can expect to be supported to take part in appropriate activities within the home and the local community; however, restricted access to parts of their home does not respect their rights and freedom of movement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are encouraged to take part in meaningful daytime activities of their own choice and according to their interests and capabilities. One of the service users has their own shed in the garden where they keep tools and equipment for gardening. They have a regular arrangement with a neighbour to maintain their garden. Service users continue to attend day care placements and leisure activities of their choice. These include ‘Woodenstuff’ and the Onward Enterprise factory in Thetford, which provides opportunities for supported work placements. Social events include the gateway club and attending college classes for arts and crafts sessions. A masseur visits the home on a weekly basis. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 14 A service user was observed making plans to go clothes shopping and had made an appointment to have their hair cut and coloured on the same day. All service users were at home during the inspection. The people carrier had broken down and had been booked in at the local garage for repair. A service user due to go out shopping had cancelled their plans due to the vehicle breakdown, however they had been offered a taxi. They confirmed that they had refused to go by taxi and chose to spend the day in their room. Service users confirmed that they are supported to carry out daily housekeeping tasks, for example, hovering and polishing their own room and changing their own bed linen. Refurbishment of the kitchen now provides service users with bright, clean, spacious and accessible facilities. They were observed preparing hot drinks and their own lunch under supervision. One service user has a weekly job sheet, which identifies tasks they have agreed as their responsibility. These include taking out the wheelie bins, filling up the soap and paper towel dispensers, washing and vacuuming the homes vehicles and keeping the garden tidy. Staff support is identified where the service users participation in these tasks have an element of risk involved. Meals are an important part of the daily routine. A four-week rolling menu seen confirmed service users are provided with a good range of meals. The supper menu for the day indicated a choice of lamb hot pot or easy tuna puff pie and salad. The menu is a guide only and service users are free to choose alternatives. Two service users chose to have the hot pot with rice and the others decided to have cheese and potato pie. A consultation with a dietician took place in January 2007 to support a service user to manage their weight. A case review was held involving the service user and staff, which included a training and discussion session covering the medical history of the service user, energy consumption and expenditure, healthy foods and portion control and diet planning. Following this session a healthy eating plan has been developed and agreed with the service user to help them reduce and monitor their food intake to regulate their weight. The kitchen and laundry doors are locked at all times. The issue of service users being secluded from these rooms was discussed with the manager. They explained that the kitchen and laundry have been locked to prevent one service users access due to their unpredictive behaviour. They have been assessed as a high risk to themselves or others by having access to these facilities. This prevents the other service users moving freely around their own home. Service users confirmed they have their own key to their bedroom and that staff hold an override key in the event of an emergency. Service users’ privacy were observed being respected, where service users had chosen to stay in their room staff only entered after knocking and waiting to be invited into their room. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21, Quality in this outcome area is good. Service users can expect to have access to health and personal care services to ensure their health needs are met. They can also expect to have specialist support, from an Occupational Therapist (OT) to assess their physical needs to ensure they have the appropriate equipment to meet their individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are being supported to access healthcare services as required. Their care plan has a section, setting out their general health, personal care, physiological and mental health needs. Service users identified as being likely to self-harm have risk assessments in place which detail where interventions are required and the actions required to minimise the circumstances where they are likely to exhibit this behaviour. A requirement was made at the previous inspection for outcomes of visits to health professionals to be recorded and their progress monitored. Inspection of the care plans confirmed that recent visits to the GP, dentist, optician and the chiropodist had been recorded. Meetings and the outcomes with physiologists and community nurse team had been recorded. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 16 Concerns have been raised at inspections dating back to November 2005 about a commode chair used by one service user which is rusty and worn and requires replacing. An environmental health officer also commented on the condition of the arms on the commode/shower chair. This still has not been repalced. However the manager confirmed an OT has assessed the service user for a custom made wheelchair and shower/commode chair. The same service user showed the inspector their bedroom; they have a hospital style metal-framed bed. The bed has bedrails attached and appeared to be very narrow. The suitability of the size of the bed and the use of the bedrails was discussed with the service user, staff and manager. A risk assessment needs to be undertaken to ensure the bed is not restricting the service users movements whilst they are in bed. Inspection of the medication procedures and Medication Administration Records (MAR) charts confirmed that staff are administering and recording medication safely and in line with the homes policies and procedures. The MAR charts confirmed a record of all medicines kept in the home and date in which they were received. Each service users has a medication profile with a list of current medication and reflects where the General Practitioner (GP) has made changes to their prescription or if medication has been stopped. Three service users are currently taking prescribed medication, none of which are controlled drugs. There are currently no service users assessed as able to self medicate. Only one service user had a photograph for identification and a pen picture about them at the front of the MAR chart, which confirmed their personal details, GP and any allergies. This information would be beneficial to staff for the other service uses taking medication. To ensure that medication is administered correctly two staff are involved in the process, they use a second signature book to confirm that medication has been administered. Evidence was seen in the service users care plans that they have an ‘ageing and death’ individual plan that reflect that these issues have been discussed with the service users and their wishes documented. However, these need to be reviewed periodically to make sure they still reflect their wishes. One service stated they were unsure if they wanted to be buried or cremated, which needs to be established to ensure that at the time if their death their wishes are respected. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23, Quality in this outcome area is adequate. Service users can expect to have their views listened to, however cannot expect to be protected from abuse or neglect until staff have received up to date training in the protection of vulnerable adults. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A previous requirement had been made for the complaints log to reflect the outcomes following a complaint to be recorded to show how the complaint was dealt with and the measures taken to improve the service. The complaints log was seen and a new system has been developed to incorporate this. However, the incidents recorded were domestic disputes amongst the service users and were not formal complaints. There has been a history of complaints made about the home by neighbours. The manager confirmed they have held a meeting with the neighbours to address these issues. Further regular meetings are planned to improve relations amongst the immediate community. Each service user has a copy of the complaints procedure in their care plan, however the copy on display in the entrance hall directed people to the Northampton address and telephone number of the Commission for Social Care Inspection (CSCI) this is incorrect and should reflect the details of the Suffolk office. An ongoing requirement (made originally at the November 2005 inspection) is for all staff to have training in the protection of vulnerable adults. Trac’s has an adult protection officer who provides this training. A training schedule reflected that adult protection training had been arranged for January 2007 but the Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 18 manager confirmed this had been cancelled. Staff spoken with confirmed that they have attended training although there are no training records to reflect this. The home has a no physical restraint policy. In circumstances where the staff are unable to reduce the anxieties of the service users, they have been trained to use studio 3 techniques. Studio 3 promotes the management of challenging behaviour in a totally non-violent, gentle and dignified way by the use of low arousal and gentle physical skills. The reactive management plan for a recent service user to move to the home states that the studio 3 walk around techniques should only be used as an absolute last resort as staff are in danger of serious harm. Staff are advised in the event of the service users behaviour becoming challenging they are to call the police and in the interim, only two confident and experienced staff are to attempt any physical intervention. The home have recognised they are not able to meet the needs of the service user and have served notice for them to find alternative placement. In the interim they have increased the staff ratio to 2-1 at all times focusing on using avoidance techniques to provide additional support the service user. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26,27,28,30, Quality in this outcome area is good. Service users can expect to live in a safe and comfortable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A requirement was made at the previous inspection for the home to implement an ongoing schedule of maintenance and decoration to ensure all parts of the home are reasonably decorated. The external grounds required alteration to provide suitable and safe access for a wheel chair user to access the home. Compass Care has invested considerable expenditure to improve the décor and facilities at Wings. The front driveway has been concreted over providing a level surface for wheelchair users and parking for vehicles. However one of the paving slabs on the path was broken and requires replacing. A new fence and gate have been erected dividing the home and neighbours property. Inside the home there has been a complete refurbishment of the kitchen and laundry. The kitchen has been opened up and fitted with new flooring and wallto-wall cupboards. Low-level surfaces have been installed to enable wheelchair users to take part in the preparation of food. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 20 The laundry has been fitted with new cupboards and a sink unit and now has a lockable metal cupboard for storage of the cleaning materials. Communal areas, such as the wet room, shower and corridors have been redecorated. However these rooms are painted an ‘off white’ and look stark and sterile. These would benefit from brighter colours and posters to create a more homely and cheerful environment. The lounge appeared to be comfortable, a selection of comfortable armchairs and sofa’s have been provided and a television, DVD and a stereo system. Radiators throughout the home have been covered with handmade radiator covers, which have been painted to blend in with the walls. The maintenance person explained that significant improvements had been made to the water supply. A new larger steel water tank has been installed which now provides greater volume of water. New boilers have been fitted which has increased the water pressure, ensuring service users have access to plenty of hot water at all times of the day. Random tests of the water temperatures in the bathrooms and shower were found to meet the recommended safe temperature of near to 43 degrees centigrade. Monthly Legionella tests are undertaken and every six months an independent company carries a microbiological test. There are plans in place for refurbishment of the bathroom. The maintenance person is in consultation with contractors to undertake the work. Currently the home has two showers (one is a wet room and the other is a step in shower), a bathroom and three toilets. When the bathroom is refurbished, the provision of an assisted bath was discussed with the manager and the maintenance person so that a choice of bathing facilities are available to meet service users individuals needs. Locks have been fitted to the doors of all the bathrooms and toilets for privacy, however staff hold an override key in case of emergencies. Service user’s bedrooms seen reflected their individual personalities and interests, with varying degrees of tidiness. One service user had damaged their hand washbasin and items of furniture, which need replacing. Most urgent was the hand basin, as this had been smashed. The maintenance person made arrangements for this to be replaced immediately. Another service users room is in the process of being decorated, a new carpet has been laid and new furniture is being purchased. The home’s arrangements for dealing with soiled clothing or bedding comply with department of health guidelines. To prevent the spread of infection in the home, the slip mats seen in the step in shower are dirty and mouldy and need replacing. Hand soap and paper towel dispensers and protective equipment such as gloves and aprons were available in all bathrooms. The premises was found to be clean and tidy with no unpleasent odours. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36, Quality in this outcome area is adequate. The current arrangements for recruitment and staffing training are not sufficient to ensure the safety and welfare of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information obtained from the pre inspection questionnaire completed in August 2006 identifies that two staff hold National Vocational Qualifications (NVQ) at level 2. The files and training records of staff identified that two new employees have achieved an NVQ. However, this does not meet the National Minimum Standards (NMS) recommended ratio of 50 of care staff should hold a recognised qualification. Staff files reflect that some staff training has taken place, including Studio 3, diet planning, first aid, food hygiene, health and safety, assertiveness and safe handling of medicines. However further training is required to ensure staff have the specialist skills and experience necessary to meet the individual needs of each service user, and should include agency staff that are used on a regular basis at the home. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 22 At the previous inspection a recommendation was made for staff to attend equal opportunities training to promote awareness of diversity and equality, this has not taken place. However a training schedule identified this as a need. Additionally the schedule identified further planned training for the coming year which, includes death and dying, sexuality, disability and cultural awareness, depression, fire safety, incident reporting, first aid and valuing relationships and boundaries. Three new employees files were seen and confirmed that each member of staff had been issued with a Compass Care Induction Programme. The purpose of the induction programme stated that this was is a stop fill for the new employee whilst awaiting registration to commence Learning Disability Awareness Framework (LDAF). The programme includes a learning log, which the new employee documents their understanding of induction issues, for example, what is a care plan. These were being monitored through the supervision process. Staffing levels have recently been assessed due to concerns relating to the behaviours of a service user. As a result staffing numbers have been reviewed and increased to meet the individuals and other service users needs. The staffing roster confirmed that 5 staff instead of 4 are on duty between 7.45am – 5.45pm and 5 staff instead of 3 between 5.30pm – 10.30pm, with 2 waking night staff. The roster also reflects that due consideration has been made to the ratio of male and female staff to meet the assessed needs of the service users. The home has been using agency staff to address staff shortages; they have however recently recruited new staff. The roster confirmed that 3 agency staff had been booked to cover the day of the inspection. One of the agency staff was working a double shift, which is a total of 15 hours in one day. The manger confirmed they would have a break between shifts, however they need to monitor the hours the agency works at the home in conjunction with elsewhere through the agency to ensure they are fit to carry out their duties. Staff files seen confirmed the home generally operates a thorough recruitment process, which includes obtaining all the appropriate paper work including Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks and in the case of overseas workers work permits. However, one employee’s file did not have an application form or two satisfactory references. Staff files contained signed copies of the terms and conditions of employment. Service user opinions had been sought and documented on the potential and suitability of the candidate before they had been offered employment. A previous recommendation was made for supervision of staff to take place, to meet the NMS recommended six supervisions a year. Each employee is provided with a supervision folder and an appraisal logbook. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 23 Each of the new staff had received supervisory sessions, which discussed service user and work related issues and identified their training and development needs. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,42, Quality in this outcome area is adequate. People living in the home can be reasonably assured that the home is run in their best interests, however the management must seek the views of service users about their care, who is admitted into the home and the services offered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Time was spent with the new homes’ manager. They have applied to become the registered manager with the Commission for Social Care Inspection (CSCI). They qualified as a registered nurse for mental handicap in 1989 and has recently achieved a nursing honours degree for working with people with a learning disability. They have previous experience of working with people with challenging behaviour, learning and physical disabilities and mental health. Most recently they have completed the studio 3 training. They do not have a management qualification and should consider undertaking a National Vocational Qualification (NVQ) level 4 in management. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 25 A previous requirement was made for the home to implement a quality assurance system to seek the views of the service users and other people that have contact with the home. The revised service user guide contains a charter of rights; which refers to a resident’s questionnaire to obtain feedback around their care and the services offered. A copy of the summary of the survey must be made available to service users, staff and a copy sent to the CSCI, to reflect how information is used to improve the service. The manager produced an incident/accident analysis form, which they complete monthly and send to their head office. There were seven recorded incidents in January, five relate to service user assault. Two were a service user assaulting another service user. Only one of these was reported as a protection of vulnerable adults incident. One occasion related to a service user self-harming and the remaining incidents were staff assaulted by a service user. Action has been taken to reduce these incidents by increasing staffing levels, however, as already mentioned in the choice of home section of this report the home must be very clear of their capacity to meet the assessed needs (including the specialist needs) of individuals moving into the home. Service users spoken with were very anxious and upset about the breakdown of placements and the behaviours of the three service users that have been asked to leave. They wish to be fully consulted on who moves into their home in the future. The home has two folders of policies and procedures; this is confusing when looking for guidance. One file contains Tracs care policies and procedures the other contains those relating to the former company of Compass Care. The home’s policies and procedures are currently under review. However these need to be consolidated in the interim to one file, which reflect current practice. To protect service users health, safety and welfare regular maintenance checks have been completed. The fire extinguishers were serviced in November 2006 and records show that the alarm system is due for a service. Additional safety checks include regular fire extinguisher checks, alarm and emergency lighting tests, water temperature and legionella checks. Records show that moving and handling equipment was last serviced in January 2006. The previous manager had been designated the responsibility to review all risk assessments and address areas of immediate concern, such as the poor lighting in corridors and the uneven drive way to improve wheelchair access. Action has been taken as part of the improved maintenace to resolve these issues, however the risk asessments need to be reviewed on a regualr basis to ensure they reflect current safe working practices. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 2 3 2 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 3 3 X 2 2 X 3 X Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 (1) (a) (b) (c) (d) Requirement The registered person must make sure that new service users are admitted to the home: • Only on the basis of a full assessment undertaken by a suitably qualified or suitably trained person. • Must be clear of their capacity to meet the assessed needs (including the specialist needs) of individuals moving into the home. • There must be appropriate consultation with the service user and/or their representative. The placement must be confirmed in writing that the home can meet the service users needs in respect of their health and welfare. 2. YA3 14 (1) (a) The registered person must ensure that the home does not offer a place to someone whose needs it cannot meet. 02/02/07 Timescale for action 02/02/07 Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 28 3. YA5 5 (b)(c) The registered person must make sure that service users have a contract, which is discussed with the service user and signed and dated by both the manager and service user. The registered person must make sure that the bed and bed rails provided for one service user are assessed by an occupational therapist or suitably qualified specialist to ensure that the equipment meets their needs and is not restraining them whilst in bed. The registered person must make sure that all the complaints procedures in the home directed people to the Commission for Social Care Inspection (CSCI) Suffolk office and not Northampton. 31/03/07 4. YA18 23 (n) 13 (7) 31/03/07 5 YA22 22 (7)(a) 31/03/07 6. YA23 13 (6) The registered person must 31/03/07 ensure that all staff attends training to prevent residents from suffering abuse or placed at risk of harm or abuse. The registered person must 02/02/07 ensure that staff know the correct procedures to follow where incidents of alleged abuse, (including where a service users assaults another service user) in line with the Suffolk inert agency policy of June 2004. The registered person must ensure that suitable arrangements are made to prevent the spread of infection. The non-slip mats in the shower were dirty and require replacing. 02/02/07 7. YA23 13 (6) 8. YA30 13 (3) Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 29 9. YA39 24 The home’s quality assurance (QA) system must be completed take into account the views of the service users and other people that have contact with the home to seek their views of how the home is achieving its goals. A copy of the summary of the survey must be made available to service users, staff and a copy sent to the CSCI, to reflect how information is used to improve the service. This is a repeat requirement from 06/04/06 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The service users guide and other information about the home are available in formats suitable for the people for whom the home is intended, for example appropriate language, pictures and where possible photographs. Service users have unrestricted access around the home and grounds. One of the paving slabs on the path leading to the house is broken and should be replaced. 50 of staff should achieve NVQ level 2 To promote diversity and equality staff should attend equal opportunities training. The home’s policies and procedures should be consolidated into one file, to reflect current practice. DS0000063585.V329033.R01.S.doc Version 5.2 Page 30 2. 3. YA16 YA24 4. 5. 6. YA32 YA35 YA40 Wings 7. YA42 To protect service users and staff health, safety and welfare risk asessments should be reviewed on a regualr basis to ensure they reflect current safe working practices. Wings DS0000063585.V329033.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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