Inspection on 20/09/07 for Woodhouse

This inspection was carried out on 20th September 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodhouse 09/06/09

Woodhouse 17/07/08

Woodhouse 18/10/06

Woodhouse 24/03/06

Woodhouse 27/09/05

Woodhouse 01/03/05

Woodhouse 17/08/04

Woodhouse 12/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Woodhouse Wigton Crescent Southmead Bristol BS10 6DA Lead Inspector Sarah Webb Unannounced Inspection 20 & 21 September 2007 09:00 th st DS0000044679.V346656.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 DS0000044679.V346656.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. DS0000044679.V346656.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodhouse Address Wigton Crescent Southmead Bristol BS10 6DA 0117 9581160 TBA woodhousemanager@shaw.co.uk 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) Shaw Healthcare (Specialist Services) Ltd Madelynne Silcock Care Home 16 Category(ies) of Learning disability (16) registration, with number of places DS0000044679.V346656.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 16 persons aged 18 years to 65 years. May accommodate two named people with a learning disability aged over 65 years. Registration will revert to 18 to 65 years when named people leave. 18th October 2006 Date of last inspection Brief Description of the Service: Woodhouse is registered with the Commission for Social Care Inspection to provide accommodation and personal care for sixteen persons with a learning disability aged 18 to 65 years. A variation has been agreed to provide care for two named persons aged over 65 years. Woodhouse is a purpose built facility, first registered in July 2003 and is situated in a residential suburb of Bristol. The accommodation is arranged over two floors, and a passenger lift is installed. Individual accommodation is provided in eight apartments on one side of the building, and eight flats on the other side of the building. The accommodation is linked by communal facilities on the ground floor. The apartments have en-suite bathroom/toilet facilities, a large living area, and optional kitchen facilities. The flats consist of a lounge, bedroom, kitchen and bathroom facilities. Individual accommodation located on the ground floor all have small patio gardens. The basic fee for this service is £2400.00 per week. The exact fee level is dependant on the support needs of each individual service user. DS0000044679.V346656.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a Key Unannounced Inspection that took place over one and a half days. The inspector met some of the people using the service and several of the care team. Both the Manager and Assistant Manager assisted with the inspection process. The inspection process included viewing records in relation to care and support plans, risk management, the administration of medication, the management of behaviours, and recruitment. Further information was also provided through the Annual Quality Assurance Assessment. A tour of the home was undertaken. Interaction between staff and people was also observed. Nine surveys were received by relatives, two from care professionals. Feedback was generally positive in the care and support offered to people. Four completed questionnaires were also received by people using the service. Feedback was also positive in how they feel they are supported by staff. As a result of this visit, 10 requirements were made including requirements needing immediate attention on the day. What the service does well: Both people spoken with and surveys returned identified that people are happy living at Woodhouse and feel well supported by staff. People’s health care needs are well met by an experienced staff team. The home has good links with local health and social care professionals and they are used to support and maintain peoples lifestyle, health and well being. The majority of surveys returned by families stated they were satisfied with the overall care their relative received. Staff treat people with dignity and respect and are sensitive to peoples personal and emotional needs. The home provides a safe, homely, clean and comfortably environment for people to live in. There is now a registered manager in place and the home is fully staffed. DS0000044679.V346656.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Information provided to prospective people wishing to live at the home needs to be reviewed so that people can make an informed decision as to whether to move to the home. The home must ensure that the preparation and cooking of all food is cooked following food hygiene regulations so as to ensure peoples health and welfare. The home must improve in the arrangements for the recording, handling, safekeeping, and administration, of medication so as to ensure people are kept safe. Staff must be provided with training in relation to safeguarding adults. The home must inform us of any incident that may affect the well being of people using the service. Documentation must be kept in staffing files to identify that they have undergone a Criminal Records check to evidence that the home protects people using the service. A record must be kept of all complaints with outcome and of people’s valuables. DS0000044679.V346656.R01.S.doc Version 5.2 Page 7 The home must ensure all fire equipment is checked regularly and that fire training takes place regularly so that people are kept safe. Risk assessments must be reviewed so that staff are supporting peoples with their changing needs consistently. 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. DS0000044679.V346656.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 DS0000044679.V346656.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, & 5. Quality in this outcome area is good. Prospective people wishing to use the service have their needs assessed prior to being admitted to the home to ensure the home is suitable for them. Information about the range of services offered needs to be updated so that people can make an informed decision to move to the home. People have a personal contract detailing the terms and conditions of occupancy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a Statement of Purpose; this includes a mission statement and philosophy of care statement. However this now needs to be updated with current information including the new managers qualifications, any changes to the staff profile and training staff have attended. The Statement of Purpose also needs to include information relating to the range of people the home offers a service to and how they are supported. This was discussed with the manager and written guidance regarding the Statement of Purpose has been sent to the home. There are currently 2 vacancies and since the last inspection two new people have moved to the home permanently. DS0000044679.V346656.R01.S.doc Version 5.2 Page 10 Care records contained comprehensive assessments of needs, with clear evidence that other health or social care professionals had been consulted about their needs. A family member spoken with said they were very pleased with the support and care offered to their relative and that their needs were being met. A member of staff who was this person’s key worker said that they had been given sufficient information so that they can support this person in meeting their needs. A survey received by a person using the service said ‘ I like living at Woodhouse. I am very happy here.’ Another person spoken with said they liked the home and the staff. All bar one survey returned by families identified that the home keeps them informed about their relatives care and any changes to their health or welfare. Admission agreements were in peoples care files detailing the terms and conditions of their occupancy. DS0000044679.V346656.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, 8, & 9 Quality in this outcome area is good. Peoples care needs are clearly identified in detailed care plans. These plans contain up to date guidance to enable staff to meet these needs including social and emotional needs. Staff demonstrate a good awareness of these issues and how they should meet peoples needs. People are supported to make their own decisions and choices and their views are listened to. The Risk Assessments process support people to take risks as part of their lifestyle, however there are some that are in need of review. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care planning and review processes within the home are good. New care planning documents were in people’s rooms and these contained four areas of peoples care and support needs. These are ‘Essential Lifestyle Plan’, ‘Support Guidelines’, ‘Healthcare’ and ‘Behaviour’. DS0000044679.V346656.R01.S.doc Version 5.2 Page 12 Care plans provide staff with detailed information in how to meet peoples needs; staff spoken to said that they were given time to look at peoples care plans prior to supporting them. Care plans described how to support each person and what boundaries or limitations may be needed for some individuals. An individuals care plans was examined; they were aware that they had a care plan and insisted that it stayed in their room. Care plans had been reviewed regularly. The home involves the placing authority and families, with a record kept of the action to be taken. The home provides a service for people who have a variety of complex needs, It was evident though discussion with staff, people using the service and a family member that people are encouraged and supported to make informed choices. Examples were given such as where people wanted to go out, choice of food and activities they wished to take part with. A survey returned from a family member indicated that they were unhappy about some care practices observed by staff in relation to their relative; however they did state that some of these issues had improved recently and that they had been invited to have discussion about their concerns. The home is still investigating ways of improving people’s involvement within the development of the service. The organisation is aware that this is an area that can be improved and the manager said that the use of more pictures/picture symbols are being implemented. People had risk assessments in their care files; these support them to take risks as part of their lifestyle and form part of each person’s care plan. There were some risk assessments that are in need of being updated. DS0000044679.V346656.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 poor. People are encouraged and supported to take part in appropriate individual leisure activities and training sessions. They also benefit from access to local community facilities, and visits to families and friends. Although a varied and healthy menu has been developed the home must ensure the health, safety and welfare of people and staff when food is prepared. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home offers people meaningful activities in which to develop their personal and daily living skills. People have their own weekly timetable of activities and some people go to differing day activities, including attending specific structured day services, and college placements. DS0000044679.V346656.R01.S.doc Version 5.2 Page 14 The home has various environments in supporting people with activities such as a sensory room and a training kitchen. People are supported individually with different tasks such as preparing breakfast. One person spoken with is supported with daily living skills in shopping for food and the cooking of their meal. People make choices about what they want to do during the day. The staff offer opportunities for people to be involved in art activities and the local community is near. Staff support people in accessing local shops, cafes, hairdressers, and going to church. People are supported in keeping in touch with their family, some people stay with their families for weekend visits. A survey returned by a relative identified that staff support their relative in making regular telephone calls between visits. Another survey related that they are always welcomed to the home and listen to their comments made. The manager said the home has not taken anyone away on holiday this year; however during the summer month’s day trips were provided. A survey returned by a family member indicated that their relative had made good progress with their daily living skills and that they had ‘become a person again.’ The home has a 3 week rolling menu; this identified that people are offered a varied and nutritious diet. The chef has an awareness of peoples differing diets and has compiled a file with peoples food preferences; both care files and information in the kitchen recorded peoples likes and dislikes. The home has started pictorial menus to help support people in making choices. A family member spoken with praised the chef saying that he was very aware of their relatives’ preferences and always made an effort to offer suitable meals. However there is some information that needs to be included specifically for one person with regard to their specific dietary needs. On the day of this visit there was an agency chef covering and it was evident that they were not following the set menu and had prepared the main meal and cooked vegetables more than an hour before the meal was due to be dished up. Temperatures of the food had also been recorded prior to completion of the cooking. The manager said it was most unfortunate that the regular cook had not been there on the day of this visit. The home must ensure that the home follows the relevant legislation (Food Hygiene (England) Regulations 2006) in the storage and preparation of food so as to ensure any unnecessary risks to the health and safety of people are eliminated. However the home has taken immediate action in investigating this incident and has reported that the agency chef will not be returning to work at Wood House. DS0000044679.V346656.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 Quality in this outcome area is adequate. The care plans provide information in how to support people in relation to their personal and health care; staff have a good knowledge of the people using the service and how to provide appropriate levels of support. The home must improve in the recording of the administration of medication and must risk assess some areas that could leave people unsafe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care files identified that peoples health care is monitored and reviewed regularly. Medical history and medical information checklists indicated that people are supported in attending appointments with differing agencies such as podiatrist, community nurse, and psychiatrist. Peoples changing needs are identified by staff and the home involves the Community Learning Disability team for specific support. An individual had been helped to access hydrotherapy as part of their assessed needs. DS0000044679.V346656.R01.S.doc Version 5.2 Page 16 Staff were seen interacting with people and it was evident that they are sensitive to peoples personal and emotional needs. An individual spoken said she was treated nicely by staff. All ten surveys returned from families agreed that staff were courteous and treated people with respect. The systems in place for administration, storage and disposal of medication were checked to monitor if the systems are safe. The medication administration charts of three people who are administered with their medication were looked at. Medication profiles contained a photograph with the drug records to help ensure medication is dispensed safely and how individuals should be approached when administering their medication. Up to date records were kept of medication received into the home. However medication received back to the home after people return from social leave must also be recorded. The medication administration charts also showed that an individual’s medication had not been signed for on the day of the visit. It was explained that although the medication had been administered, the person had initially refused to take it but had taken it at a later time. Staff also identified another person who refused to take their medication on a regular basis; that on occasions they pretended to take it but kept the medication. This presents unsafe practice for people living at the home and it is clear that the home must improve in keeping people safe. Risk assessments must be completed for those people refusing to take their medication and for medication that is not taken and being left unsecured. Senior staff administer medication, the majority of whom are nurses and have been trained in medicines. Those senior staff not qualified nurses complete a national vocational qualification in the administration of medication. The home has met a recommendation to consider reviewing the medication administration and storage relating to Buccal Medazalam in line with ‘Joint Epilepsy Council’ guidance DS0000044679.V346656.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. The complaints policy and procedure is clear and is accessible to the people using the service. People feel their views are listened to and acted on. However, the home must ensure that a record is kept of all complaints and the outcome action taken. Clear reactive strategies are in place for people who present challenging behaviour. Although risk assessments have been improved in relation to Positive Response Techniques, people would benefit from a better system for recording all incidents when people are challenging. The staff team are provided with training and support to ensure the welfare and safety of people. However, this must be provided consistently for each member of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a formal complaints policy and procedure in place to ensure that all stakeholders are listened to. The manager was made aware of our new contact details during the visit so that these can be changed within the procedure. A requirement has been met for all stakeholders to be made aware of the home’s complaints procedure. An enclosed notice board is now displayed in a communal lounge, which holds a pictorial procedure. An individual spoken with said they knew who to go to if unhappy and had any concerns. DS0000044679.V346656.R01.S.doc Version 5.2 Page 18 Surveys returned from people also identified that they would go to staff if they had any concerns. Although there have been no formal written complaints logged since the last visit, the manager related a verbal complaint made by another agency that was not able to be substantiated. The manager was unable to follow this up due to the lack of information given by the informant and said she had tried to pursue for more information. The manager must ensure all complaints made are recorded with the outcome of any investigation. There are no formal meetings involving the people using the service due to their complex needs. It is felt by staff that formal meetings are not appropriate to both the communication and behavioural needs of people. People continue to be consulted on an individual basis and those with families are supportive. The manager said in some cases the individual’s social worker would be their advocate. A recommendation was made regarding contacting advocacy services for those people who did not have families to advocate on their behalf. This is carried forward through this visit. A compliment has been made recently by a specialist service in that they feel the home has improved in the staffs’ awareness to peoples needs. The home has guidelines in place for supporting people who are distressed or presenting behaviours which may be perceived as challenging to the service provided. Staff receive training in responding to these behaviours using the Positive Response Techniques system (PRT), which is accredited by the British Institute of Learning Disabilities. Care files contained risk assessment and risk management records. A requirement has been met for the risk assessment process to be improved relating to the use of PRT. A survey returned by a professional related that the home is meeting the needs of an individual that they have placed and that specific procedures have been put in place to support them and to ensure their safety. Reactive strategies included individual’s indicators in changes in behaviours and how these may be dealt with. All incidents are recorded with people’s behaviour monitored. However people would benefit from the home expanding on their information provided and to include in records the description of the incident, diffusing techniques used, staff members involved, timings and details of any physical interventions used. This will help to monitor people’s behaviour better. DS0000044679.V346656.R01.S.doc Version 5.2 Page 19 Daily notes also record any changes to people’s behaviour and how they have been dealt with. The home also maintains records of other accidents and incidents but has not always notified us of significant events that occur in the home. The home was without hot water for a significant period of time; the lift was also out of action, impinging on a person using a wheelchair, in that they were restricted from accessing the lower floors. An immediate requirement was made for the home to inform us of any incident that may affect the wellbeing of people using the service. The home has policies and procedures to follow in ensuring the protection of vulnerable adults. A senior staff member has recently completed a trainers course for delivering safeguarding training to staff. Staff spoken with identified that they had received abuse awareness training during their induction period. However the training matrix identified that there were still gaps were some staff had not received training. The home has followed appropriate action in relation to a recent allegation made by an individual and has involved all agencies involved in the care of this person. An outcome from this incident has determined the manager in developing a specific protocol to be developed for alleged incidents taking place. People’s finances are well recorded with receipts kept individually. Those cash balances examined were found to be in order. The manager explained that the organisation has had difficulty in opening up individual bank accounts for people and that the current practice continues in that the organisation operates a system whereby 9 people have a joint account with Shaw healthcare where their monies are held centrally. DS0000044679.V346656.R01.S.doc Version 5.2 Page 20 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, 29, & 30 Quality in this outcome area is good. People benefit from living in a safe, homely. clean and comfortable environment and have a furnished apartment/flat to suit their individual tastes and needs. The home has redecorated several areas through a planned maintenance programme. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Woodhouse is a 4 year old purpose built home, set in its own grounds. A full tour of the property was undertaken during this visit and all areas of the home were found to be clean, homely and comfortable. Surveys returned by people also said the home was always fresh and clean. The home employs 2 domestics to also help ensure the home is clean. DS0000044679.V346656.R01.S.doc Version 5.2 Page 21 All communal areas of the home were viewed, together with some people’s apartments or flats; these were personalised with individual’s belongings, pictures and photographs. The fixtures and fittings in these areas were of a high standard. A person spoken said they liked their apartment and spent a lot of time there during the day Since the last inspection, the environment has been improved in a number of areas. Several of the communal areas have been redecorated giving a fresh feeling to the home; laminate flooring in place also gives the appearance of space. Communal areas supported artwork and prints; this helps the environment to provide a homely atmosphere. The life skills kitchen is used by people to make snacks and meals of their choice. Timetables in peoples care files also identified that this is an area used in supporting people with their daily living skills. A spa room containing a hot tub is currently only used by 2 people. The manager said that not everyone likes this therapy. However, the relaxation room has been completed since the last key inspection and has been refurbished with appropriate sensory equipment. The manager said it was a popular venue for people to relax and is frequently in used. A ‘media’ room is also available for people to use and has a computer that is used with staff support. There is a specific laundry area where some people are supported in helping with their washing. A survey returned from a relative indicated that they had concerns about the laundry service and that there have been occasions when their relatives clothing has been mislaid. This was passed on to the manager. The home has a maintenance person who is employed for 20 hours a week. Their role is mostly to redecorate people’s apartments/flats and other minor tasks. Larger areas of maintenance are dealt with through contractual arrangements. Since the last inspection, the trees have been cut back to provide more light to the home. The lawns surrounding part of the home are maintained monthly. Some people are also involved in the gardening and a staff member indicated that during the summer months people helped with planting the tubs on the patio area. The manager said a quote has been forwarded to improve the garden area with a sensory garden. DS0000044679.V346656.R01.S.doc Version 5.2 Page 22 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): 31, 32, 34, & 35. Quality in this outcome area is adequate. Staff have a good awareness of their roles and responsibilities; an experienced staff team has now been fully recruited. Staff files must contain all relevant information to evidence that the home follows a robust recruitment process that ensures the protection of people. Staff attend appropriate training so that they are provided with the guidance and skills to meet the needs of people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a large team of support workers including a core team of bank workers; the home is now fully staffed. Team leaders supervise support workers whilst senior support workers provide advice to support workers. Four staff were spoken with; they identified their previous work related experience and demonstrated a good knowledge of their roles and responsibilities. DS0000044679.V346656.R01.S.doc Version 5.2 Page 23 The rota was examined to show the staff numbers on duty. There are 13 support staff on duty at any time with 1 team leader in charge from 7.30am – 3.00pm. Additional support workers may also be supporting people on a 2:1 basis. The second shift of the day is from 2.30pm – 10 00 pm. It was evident that there are sufficient staff on duty to meet the needs of people. Seven staffing files were examined to assess the recruitment practice of the home. All had application forms; 2 files had both references required whilst 1 file had only 1 reference. There were 4 files that had no references in place. Although the manager showed that all the returned Criminal Records Bureau (CRB) checks and Protection of Vulnerable Adults checks (POVA) were stored on her laptop, there was no written confirmation in staffing files. This information needs to be available for future inspections, and the administration officer began this process during this visit. An immediate requirement was made for this to be implemented. Since the visit the home has responded identifying that this has now been completed. The administrative officer also identified that whilst she has been away that some of the processes have got behind. There were also some gaps in the records of induction offered to new staff. Staffing files seen identified that whilst 2 staff had written induction material in their files, there were 4 staff who appeared to have not had any induction. However staff spoken with said that they attend organisational training during their induction that includes attending training in health and safety, and policies and procedures. New staff also ‘shadow’ a staff member initially prior to working on their own. This was also verified by the staff spoken with. Staff complete Learning Disability Award Framework (LDAF) Induction and Foundation; the home now has a National Vocational Qualification provider and plans to book 30 staff to start a level 2 qualification. Team leaders covers differing areas of support and training. One team leader leads on communication within the LDAF and provides workshops for staff in this area. Both a team leader and support staff spoken with indicated that the home practices good communication through both regular staff and team leader meetings. The training matrix indicated areas that staff have attended, including moving and handling, risk assessment, health and safety, food hygiene, and infection control. The majority of staff had completed training in these areas; however there were some gaps and the manager is aware that some staff need to be updated in some of these areas. DS0000044679.V346656.R01.S.doc Version 5.2 Page 24 Several areas such as epilepsy, autism, and dementia, have been covered by the Community Learning Disability Team. The manager provides PRT training and said challenging behaviour and communication are incorporated in these sessions. A supervision matrix evidenced that the home has better processes in place for the regular supervision of staff. Staff receive appraisals in line with the organisational policy. DS0000044679.V346656.R01.S.doc Version 5.2 Page 25 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): Quality in this outcome area is adequate. The home has effective procedures in place to provide people with the support they require. There is now a permanent registered manager in place. The views of people are actively being sought in relation to the quality of the service. The health, safety and welfare of people must be improved in relation to fire safety procedures operating in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ms Silcock was registered as the Manager of the home in June 2007. She has completed the Registered Managers Award. It is evident that Ms Silcock has a clear understanding of her role and has made improvements to the home in several areas. She considers one of these improvements to be in the areas of supporting people consistently. DS0000044679.V346656.R01.S.doc Version 5.2 Page 26 It is evident that the home supports a person centred culture listening to people and acting on their views. Staff spoken with said their views are listened to, and that they are well supported by the manager. A survey returned from a family member also identified that the home had improved since the new manager took over. The fire logbook was examined and it was noted that the fire alarm testing was not consistent with the timescales prescribed by the Fire Brigade; there were also some gaps in fire equipment checks. A new staff member spoken with said they had not been instructed in fire safety procedures. This was verified with a team leader. The home must ensure all staff are trained in all matters concerning the fire safety of the home to ensure peoples safety. DS0000044679.V346656.R01.S.doc Version 5.2 Page 27 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 X 5 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 1 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X DS0000044679.V346656.R01.S.doc Version 5.2 Page 28 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. 2. Standard YA1 YA17 Regulation 4 16(2)(i) Requirement Update the Statement of Purpose to include current and relevant information. Food Hygiene (England) Regulations 2006) The home must ensure that relevant legislation is followed in the storage and preparation of food so as to ensure any unnecessary risks to the health and safety of people are eliminated. Make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home. This relates to the need to: 1) Risk assess those individuals action to refuse to take medication and the security of medication when not taken. 2) Ensure all medication administered is signed for by staff. DS0000044679.V346656.R01.S.doc Version 5.2 Page 29 Timescale for action 31/01/08 22/09/07 3. YA20 13(2) 22/09/07 4. 5. YA23 YA23 13(6) 37 6. YA34 Sched 4 7. 8. YA22 YA42 22 23(4)(c) 9. 10. YA9 YA41 13(4) Sched 4 3) Keep a record of medication returned to the home after people have been on social leave. Immediate requirements issued. Provide staff with training in the safeguarding of adults Inform us of any incident that may affect the well being of people using the service. Immediate requirement issued Keep documentation in staffing files to identify that they have undergone a Criminal Records check. Immediate requirement issued Keep a record of all complaints and action taken. Ensure fire equipment is checked regularly and that fire training takes place regularly. Update risk assessments. Keep a record of peoples valuables. 31/12/07 22/09/07 20/10/07 22/09/07 20/10/07 31/10/07 31/12/07 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. 2. Refer to Standard YA23 YA6 Good Practice Recommendations To obtain/investigate advocacy services from independent organisations for those residents in need Investigate accessible, pictorial formats and information for people DS0000044679.V346656.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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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