Inspection on 06/04/06 for Wings

This inspection was carried out on 6th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Wings 01/02/07

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 Seddon Unannounced Inspection 6th April 2006 10:00 Wings DS0000063585.V288135.R01.S.doc Version 5.1 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.V288135.R01.S.doc Version 5.1 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.V288135.R01.S.doc Version 5.1 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 Mrs Joy Sonia Bentley Care Home 6 Category(ies) of Learning disability (6), Mental disorder, registration, with number excluding learning disability or dementia (6) of places Wings DS0000063585.V288135.R01.S.doc Version 5.1 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. 23rd November 2005 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 three vehicles 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. Joy Bentley is the registered care manager. The home has a detailed statement of purpose providing information for prospective service users issued on request. Each service user has been issued with a contract, which was reviewed on the 1st December 2005 stating the current fee. The fees range from £1676.00 to £2237.66 per week. The service user guide requires updating which will provide additional information to prospective service users, including the most recent inspection report by the Commission for Social Care Inspection (CSCI). Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over seven and three quarter hours. This was a key inspection, which focused on the core standards relating to adults, aged 18-65. The report has been written using accumulated evidence gathered prior to and during the inspection. This included reviewing the home’s statement of purpose and other documents required under the Care Homes Regulations. These documents were previously supplied to the Commission for Social Care Inspection (CSCI) by the home. Additionally a number of records held at the home were looked at during the inspection including those relating to service users, staff, training, service user guide and policies and procedures. Time was spent talking with two of the service users, the deputy manager, two staff and a volunteer. What the service does well: What has improved since the last inspection? What they could do better: The home needs to ensure that records are made following the outcomes from appointments and visits from health professionals. Systems need to be implemented to ensure that medication is administered and signed for correctly. An effective and robust complaints procedure needs to be implemented to ensure the concerns of service users and other complainants are listened and responded to. To ensure the health, safety and welfare of service users a system of checking staff against the protection of vulnerable adults register should be introduced and the policy and procedures for infection control and storage of cleaning materials reviewed. Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 6 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. Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 7 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.V288135.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5, Prospective service users have the opportunity to try out the home and are provided with information to make an informed choice of where to live. Service users can expect to be consulted on who moves into their home. EVIDENCE: The statement of purpose was updated following the last inspection in November 2005 and now contains relevant and detailed information for prospective service users. The service user guide needs amending to reflect changes within the company and the name and photographs of the previous partners of Compass Care removed. The service user guide also needs to include a summary of the revised statement of purpose, terms and conditions, a contract and the most recent Commission for Social Care Inspection (CSCI) report. Each service user should have their own copy of the service user guide; there was no evidence in the service users care plan to suggest they have received a copy. Wings, although registered for six service users, until January this year had five service users living at the home. The manager was concerned about filling the vacancy due to the compatibility of a new service user moving into an established service user group. A service user has recently moved into the home from another Trac’s home. Service users living at Wings already knew them and were fully consulted in the transfer of the service user to the home. The deputy manager confirmed that the service users have accepted the sixth person into the home with no major problems occurring. Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 9 The home has a very detailed admissions criteria, which is set out in five stages including, referral, assessment, consultation to discuss if the home can meet the service users needs, a trial visit and admission. Evidence was seen that the home had followed their procedures. Evidence was seen that the manager of Wings had completed an Autistic Spectrum Disorder Assessment prior to the service user moving into the home detailing the service user’s current needs, which formed the basis of the service user’s care plan. Previous documentation included a needs assessment completed in September 2005 by the placing authority’s care manager. Discussion with the service user confirmed that they had visited the home on a number of occasions and stayed for a trial period before moving into the home. They told the inspector they were happy living at the home. Service user’s contracts have been updated to reflect the owners of Wings and the service users current fee. Copies of the contracts were seen on each service users care plan. However feedback from the Commission for Social Care Inspection Care home’s surveys reflects service users are unaware of their contracts. The contracts were not signed by the manager or the service user. Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10, Service users can expect to have detailed plans identifying the level of support they need, but cannot expect to be fully consulted on issues relating to them. EVIDENCE: The home has implemented a new care plan format based on a person-centred approach. The care plans of two service users were inspected to track their care and the level of support they required. Between December 2005 and February 2006 the Commission for Social Care Inspection (CSCI) received notification on five separate occasions regarding the agitated and aggressive behaviour of one of the service users. The inspection focused on how staff help to support and manage the service users behaviour. Discussion with the deputy manager and looking at the service user care plan reflect that the service user has a detailed behavioural management plan in place, which focuses on their positive behaviour, ability and willingness to minimise the number of incidents. The home has close links with the psychological mental health team who support the service users and staff through training and assisting in the development of behavioural plans for each of the service users. Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 11 The behavioural plan reflects interventions and structured routines to reduce the service users anxiety, and enable them to live their life as they choose in the home and within the community. Where there are restrictions and limitations these have been identified and recorded. One of the service user’s social worker had visited them to discuss their current pattern of behaviour. The care plan had recorded the visit, stating the social worker would return in February 2006 to review the service user’s placement. There is no record of this meeting-taking place. The deputy informed the inspector that the social worker had resigned and that they have been allocated a new social worker. A new review date is to be made. One service user’s care plan stated that they have six monthly appointments with a consultant from the learning disabilities team and regular visits by the community psychiatric nurse. However, there was no documentation recorded in the care plan of the outcomes of these visits. The service user’s care plan was updated in December 2005. However there was no evidence to show that the service user had been involved although it clearly stated in their objectives that due to the service users complex needs they must be consulted on decisions about their life. The deputy manager told the inspector their key worker would have discussed the care plan with them. Likewise the care plan of the new service user stated that they must have regular key worker sessions to discuss anxieties and concerns but there was no record to suggest these took place. Service users records are kept secure and confidential in the staff office. The care plan seen for the new service user provided detailed assessment of their needs. This was supported by a health action plan completed by a psychologist. Both plans described coping strategies agreed with the service user and staff for anger management. Detailed risk assessments had been completed for both service users in all aspects of their daily lives. The assessments were comprehensive, detailing the hazards and likely outcomes of each identified risk. The assessments identified staff intervention to minimise the risk, whilst supporting the service user to maintain their independence. The inspector asked the deputy about service users access to independent advocacy groups. Currently no service users use this service. Service users are encouraged to take part in weekly meetings to discuss the running of the home and outings. Minutes of the meetings were seen, there appeared to be several occasions where the meetings did not take place, particularly evident whilst the manager was on sick leave. On some occasions it was recorded that the service users declined to attend the meetings. Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17, Service users can expect that they will have their rights respected and be supported to take part in appropriate activities within the local community and have the opportunity to mix with other adults. EVIDENCE: Evidence was seen throughout the inspection that staff support the service users to access opportunities for maintaining and developing their social emotional and independent living skills. The home has supported one service user to purchase their own vehicle through Motability. This has enabled them to access the community more frequently to pursue their chosen activities. A local college provides a tutor who visits the home to undertake art and craft sessions once a week. They were present on the day of the inspection. They provide continued education for people unable to access the college. They spent time with one of the service users designing hand painted motifs on a Tshirt. The tutor spoke highly of the staff about their knowledge and understanding of the service users needs and how they provide service users with opportunities to achieve independence. Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 13 One service user attends The Barns Autistic Centre where they spend time pursuing activities of their choice including drawing and playing the piano. They have also been included in various trips out to places such as Thetford and Newmarket. This was confirmed in discussion with the service user and was referred to in their care plan. Two service users continue to attend day care service called Woodenstuff and the Onward enterprise factory in Thetford, which provides opportunities for supported work placements. Another service user told the inspector that they were employed by one of the neighbours to do gardening work and they said they also look after the garden at the home. Service users are supported to access a range of leisure activities including going to the pub to play snooker and to go shopping. One service user is a well-known member of the congregation of a local church used by the American air base and attends on a regular basis. Two service users generally attend Gateway club on a Thursday evening, where they are have the opportunity to mix with other people. Other leisure activities include listening to music and watching television. Each service user has a structured activity plan, which plays an important part of the service users behavioural management. An integral part of these plans is to encourage service users participation in chores to do with running of the home. Each service user takes a turn to choose the daily menu. Menus are agreed two weeks in advance, therefore each service user can chose two of their favourite meals. If they do not like what has been chosen for the day they are able to choose an alternative meal. Service users observed eating their supper of chicken and vegetables. Evidence was seen that the food was freshly cooked and looked appealing and appetising. Throughout the inspection staff referred to the service users and staff team as “family” or making the home as “family orientated as possible”. The home has a long-standing staff team, which has provided consistency and a stable environment for the service users. There is a danger that staff could be seen to be paternalistic, however observation during the day showed that service users are treated as individuals and supported to maximise their independence. Staff were observed speaking with service users directly, clearly explaining events so that the service user was aware of circumstances involving them personally. They were also observed calling service users by their preferred name as recorded in their care plans. Evidence was as seen that service users’ right to privacy is respected where two service users had chosen to stay in their rooms. Staff were observed only entering their rooms after knocking and waiting to be invited into the room. Each service user has a key to lock their bedroom door, however staff do have an override key in the event of an emergency. Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21, Whilst the home has very detailed care plans in place, service users cannot expect to have their physical and emotional health needs monitored. Service users are not protected by the home’s procedure for dealing with medication. EVIDENCE: The service user group at Wings is made up of six individuals with very diverse needs and these are recognised in the service users care plans. Each service user has detailed plans, which are structured to provide consistency of care and daily routines. The inspector was informed these are discussed with the service user to obtain their preferences of times they get up, go to bed, rest and activity times. They also reflect the level of support they need to achieve their chosen activity. Evidence was seen in the care plans that service users are supported to access healthcare. However, records were not completed to follow up outcomes of the visits, in one instance a visit to the dentist made reference to a follow up appointment to be made, nothing was recorded to suggest this happened. Service user communication needs are assessed. Currently all the service users are able to read and speak clearly, but do need staff support to ensure that they are fully aware of the context of information so that service users are kept informed of issues that affect them personally and in the home. Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 15 A member of staff was observed administering the lunchtime medication. Inspection of the Medication Administration Records (MAR) charts showed there were several gaps where medication had not been signed as given, or a code entered to reflect if medication was not given. It was therefore difficult to ascertain if service users had been given their medication. Also the home has a system where another member of staff signs a second signature book however, the signatures did not correspond with the MAR charts. Staff informed the inspector they were currently completing medication workbooks as a training exercise and will be completing an examination on completion of the workbooks. The staff thought the workbooks were good, improving their knowledge and will make them more careful when administering medication. A record was kept of regular pharmacy visits to the home; the last visit was in March 2006, with no recommendations. Evidence was seen in the service users care plans that their wishes in the event of death and dying had been sought and recorded. However these had not been updated and need to be reviewed periodically to make sure they still reflect the express wishes of the service user. Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23, Service users can expect to have their views listened to but cannot expect to receive a detailed response. Service users can expect to be protected from abuse, neglect and self-harm. EVIDENCE: The home’s complaints procedure is included in the statement of purpose and service user guide. Additionally each service users care plan has a copy of the complaints procedure. The contact details in one service users care plan referring people to the Commission for Social Care Inspection (CSCI) were incorrect, directing people to the Northampton address and telephone number, not the Suffolk office. The complaints register showed there have been three complaints made since the inspection in August 2005, when the register was last inspected. Two complaints were made by service users and one by a neighbour. Although the complaints were logged, there was no audit trail to suggest how the complaints had been responded to or if an investigation had taken place. There was no record of the outcomes following these complaints. A requirement made at the November 2005 inspection was for all staff to have training in the protection of vulnerable adults. The deputy manager informed the inspector that all staff (with the exception of three) had attended in house training. Trac’s has an adult protection officer who provided the training. Staff spoken with confirmed that they attended the training in February this year and that they were waiting for their certificates to be issued. They told the inspector that the training was very good and that it had raised their awareness to what constituted as abuse. Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 17 Physical and verbal aggression by service users is well managed by the home. They have detailed risk assessments in place, which identify triggers and steps to take to minimise the service users anxieties, therefore the home does not use physical restraint. Where service users are likely to self-harm behavioural plans and risk assessments are in place to prevent or reduce the likelihood of these incidents occurring. In circumstances where the staff are unable to reduce the anxieties of the service users, they have strong support links with the local police who help manage the situation without the need for restraint. Evidence was seen that service users are supported, where possible to be in control over their own financial affairs. One service user returning from shopping had been to the bank to withdraw some money. The carer assisting the service user had entered the amount of money onto the service users ledger sheet, held in the office showing a record of all transactions providing an audit of expenditure. The service user chose to keep their money in a lockable cabinet in their room. The financial ledger and balance in their money tin was checked during the inspection and found to be accurate. Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30, Service users can expect to live in a home that meets their needs in a safe and homely atmosphere, however there needs to be a continued programme of decorating and maintenance of the home and equipment. The home needs to review policies and procedures for infection control. EVIDENCE: Wings is located on the outskirts of Mildenhall village and has easy access to local amenities. It is a purpose built bungalow, which is in keeping with the other bungalows in Beck Row. The home provides a range of communal areas and six individual bedrooms. Service users have the option to spend time in their rooms alone or to integrate with the others in the communal dining room, lounge and gardens. The home has wide corridors and doorways providing easy access for wheel chair users, however the front entrance/car park is covered in shingle. The path from the car park to the main entrance is narrow and uneven making it very difficult for wheel chair users to access the building. The home has been undergoing a programme of redecoration. Some improvements have been made, however the home could do with being made to look brighter providing a more homely atmosphere. Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 19 One service user’s bedroom seen was clean and tidy and decorated with their own items of furniture. They also had paintings and drawings they had done on display. The home has one bathroom and two shower rooms, each with a washbasin and toilet which has locks fitted for privacy. Inspection of the laundry room raised a number of concerns. These issues are discussed in the conduct and management of the home section of this report. Outside the laundry door, four mops were propped up against the wall, one had fallen over into the dirt. The staff identified the mops by the colour coding, however the mop used to wash the kitchen floor was propped up against the mop used for wiping up spillages in the bathroom. The mops need to be stored properly to prevent contamination. Infection control training materials issued by Trac’s were being used to train staff. Some staff had completed the training, which covers waste management, dealing with laundry, domestic and cleaning materials. 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. At the last inspection in Novemeber 2005, some of the equipment used for service users personal care and hygiene had been adapted on the instructions of a carer, equipment was looking rusty and worn and required replacing. A recquirment was made at the inspection in November 2005 that where service users are provided with aids, adaptations and equipment these must be assessed by an occupational therapist or suitably qualified specialist to ensure that the equipment meets the needs of the service user and comply with health and safety. The commode chair used by one service user had not been reapired or replaced, although the member of staff did advise the inspector that they had made several requests to the maintenance team to look into the problems. The environmental health officer also commented on the condition of the arms on the commode/shower chair. Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36, To ensure service users are protected by the home’s recruitment procedures a system for the renewal of criminal records bureau checks (CRB) should be in place, which includes a protection of vulnerable adults (POVA) check. The home provides a good range of training, however to promote diversity and equality staff need to attend equal opportunities training. EVIDENCE: The file of a member of staff was looked at, all appropriate checks had been taken up prior to them commencing employment in 2003, however, the member of staff had recently changed their role. The company had issued the staff with a new contract of employment and job description, but had not taken up a new criminal records bureau (CRB) check to include a check against the Protection of Vulnerable Adults (POVA) register. A programme of renewal of CRB’s is recommended every three years to include a POVA check. The staff roster reflected the normal working ratio of 4 staff between the hours of 8am – 6pm and 4 staff 12 – 10m, with 2 waking night staff. The staffing levels for the day of the inspection were 1 member of staff short for the late shift. However the deputy told the inspector that as it was half term, there was no Gateway club, which would normally involve staff accompanying service users and therefore 3 staff would be able to manage. Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 21 During the course of the inspection, the inspector spoke with 2 agency staff, a volunteer and 2 permanent staff. They confirmed that they felt staffing levels were adequate to meet the needs of the service users. During discussions with staff they highlighted an issue that one service user in particular relates better to male care staff. Currently the home does not employ a male carer. The home has recently recruited two new staff, one of each gender and are waiting for confirmation of all security checks prior to commencing employment. The home has been using male agency staff to support the service users needs. The agency was spoken with and confirmed that they had experience of working with people with mental health needs and had been given advice and support from staff on how to meet the needs of this particular service user. All staff spoke of feeling well supported by the manager and each other, they felt that staff morale was good creating an effective and stable support team for the service users. Evidence was seen that supervision takes place, however frequency does not meet the recommended six supervisions a year. Supervisions records reflected that issues relating to the care of service users, work issues, training and what additional support the staff needed to help them do their job. Evidence was seen that training was taking place on a regular basis, including basic core training in fire safety, food hygiene, health and safety, first aid, adult protection and moving and handling. Other training specific to the needs of the service user group had taken place, which included, borderline personality disorder, behaviour and self-injury, supporting positive approach for people with disabilities and managing challenging behaviour (Unisafe) training. There was no record of training for promoting equality and diversity, although staff spoken with had a reasonable understanding of equality and diversity, recognising that individuals have rights. Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38,39,40,42,43, People living in the home can be reasonably assured that the home is run in their best interests. However to protect their health, safety and welfare further work needs to be carried out on risk assessments and significant findings recorded and actioned. Also there needs to be a review of policies and procedures for the storage of cleaning materials EVIDENCE: As the manager was at college on the day of the inspection the inspector spent time with the deputy manager. Discussion took place about the day-to-day running of the home. The deputy is relatively new in their role and has helped to manage the home during a difficult period of change during the take over of the home by Trac’s. The manager has recently returned from sick leave, the deputy feels that the home can now move forwards as Trac’s are a good company and they felt that they would make improvements to the service. Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 23 The previous inspection noted that staff morale had improved following the dismissal of a member of staff; however, the responsible individual reports noted that staff morale was low. The deputy confirmed that issues had occurred during the Christmas period around staffing levels and pay, however Trac’s have introduced staff benefits, which have helped to resolve some of these issues. Trac’s have a quality assurance system manual. This was updated in May 2005. The manual contains all their policies and procedures and acts as a reference tool for staff. The manual states that Trac’s employ an external company to audit a selection of their homes and headquarters twice a year to measure how they compare to their policies and procedures. They also have a team of internal auditors that conduct audits of all the homes. However the deputy manager was not aware that an audit had been completed at Wings. The inspector was present at the staff hand over meeting between the shifts. Staff gave a detailed account of activities each service user had been involved in, their general well being, what support they had during the course of the shift and feedback from a hospital appointment. Other issues discussed forthcoming party and preparations for a service users birthday celebrations for the weekend. The responsible individual visits the home on a regular basis and sends a copy of their report to the Commission for Social Care Inspection (CSCI). Evidence gathered from these reports prior to today’s inspection highlighted issues around health and safety. The reponsible individual had instructed the manager to risk assess areas of immeddiate concern, for example lighting in corridors (which are dark at both ends), patio doors in the lounges which open onto each other and the drive way to improve wheelchair access. Some of the identifed risk assessments have been completed, however these need to be updated to reflect what actions are planned or have been taken to resolve the issues. The home has recently had an environmental health inspection, which confirmed that the manager needs to consider the organisation of the health and safety records and include health and safety issues at regular staff meetings. Although the cupboard in the laundry room holding cleaning materials was locked the lock was not secure. Also one of the doors was damaged exposing a thin layer of chipboard. The cleaning materials within the cupboard had been decanted into unmarked bottles with no information about the contents or safety advice in case of spillages. The inspector was informed that the laundry is scheduled for refurbishment. The registration certificate was displayed in the entrance hall; both parts were shown and had the correct information. The home’s insurance policy also on display expires in May 2006. Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 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 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 2 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 3 3 3 2 3 X 2 3 Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5 Requirement Timescale for action 02/06/06 2. YA5 3. YA8 4. YA19 5. YA20 The service user guide must be reviewed to include items 1-5 as set down in Regulation 5 (5.1) and a copy provided to each service user and the CSCI. 5 (b)(c) The service users contract must be discussed with the service user and signed and dated by both the manager and service user. 24. 3 Service users must be fully consulted on issues and decisions relating to their every day lives, to minimise concerns and anxieties. 14.2 (a)(b) Outcomes of visits to health 15 2 (b) professionals must be recorded to monitor the physical and emotional health needs of the service users. 13.2,sch,3.3,i, To eliminate any unnecessary 13.4,c risks to service users health and safety arrangements must be made for the recording, handling, safe administration and disposal of medicines and a record of all medicines kept in the home and date in which they are DS0000063585.V288135.R01.S.doc 02/06/06 02/06/06 12/05/06 06/04/06 Wings Version 5.1 Page 26 administered. 6. YA22 Sch 4 (11) Outcomes following a response to a complaint must be recorded to show how the complaint was dealt with and the measures taken to improve the service. An ongoing schedule of maintenance and decoration to make sure that all parts of the home are reasonably decorated and the external grounds are suitable, safe and appropriately maintained to allow wheel chair users access the home Where service users are provided with aids, adaptations and equipment these must be assessed by an occupational therapist or suitably qualified specialist to ensure that the equipment meets the needs of the service user. The equipment must be kept repaired and in good condition to comply with health and safety. This requirement is outstanding from the last inspection. Suitable arrangements must be made to prevent the spread of infection in the home. The home’s quality assurance (QA) system must 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 QA report must be made available to service users, staff and a copy sent to the CSCI, to reflect how information is used to DS0000063585.V288135.R01.S.doc 12/05/06 7. YA24 23 2 (a) (d) 23/06/06 8. YA29 23 (c) (n) 02/06/06 9. YA30 13.3 12/05/06 10. YA39 24 23/06/06 Wings Version 5.1 Page 27 improve the service. 11. YA42 13,4,a,b,c To protect service users health, safety and welfare further work must be carried out on risk assessments and significant findings recorded and actioned, to include the use of hazardous materials. 12/05/06 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 YA34 Good Practice Recommendations A programme of renewal of criminal records bureau checks (CRB) is recommended every three years to include a check against the protection of vulnerable adults (POVA) register. To promote diversity and equality staff should attend equal opportunities training. Evidence was seen that supervision takes place, however the frequency should meet the recommended six supervisions a year. 2. 3. YA35 YA36 Wings DS0000063585.V288135.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 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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