Inspection on 14/01/08 for Woodside Farmhouse

This inspection was carried out on 14th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodside Farmhouse 08/12/08

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 Woodside Farmhouse Edgecumbe Road St Austell Cornwall PL25 5SW Lead Inspector Ian Wright Unannounced Inspection 14 January 2008 09:30 th Woodside Farmhouse DS0000070376.V352930.R02.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 Woodside Farmhouse DS0000070376.V352930.R02.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. Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Woodside Farmhouse Address Edgecumbe Road St Austell Cornwall PL25 5SW 01726 77401 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) Meadowbank Care (St Austell) Ltd Mrs Sharon Irene Westwood Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability (Code LD) The maximum number of service users who can be accommodated is 5. Date of last inspection New service registered August 2007 Brief Description of the Service: Woodside Farm House has only been registered with the commission July 2007 to provide accommodation, care and support for up to five people with a learning disability. Woodside Farm House has been completely refurbished, and these refurbishments meet the National Minimum Standards which were introduced in 2002. Subsequently accommodation is spacious with en suite bedrooms and several communal areas. All decorations and furnishings are new and modern. The care home has four vehicles to assist the people living in the home be part of the community. The registered provider owns another care home in Devon. The provider visits Woodside Farm House at least on a monthly basis. The registered manager provides support and leadership to the staff team on a day to day basis. There is a large staff team of twenty one which provides support to the people living in the care home. The fees are currently from £2151.83 per week, although care packages are agreed on an individual basis. Further copies of this inspection report should be available from the registered persons, or from CSCI. CSCI contact details are outlined on the last page of the report. Copies of the report can, for example, be downloaded from our website at www.csci.org.uk. . Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection took place in eleven hours over two days. All of the key standards were inspected. The methodology used for this inspection was: • To case track two people who use the service. This included, where possible, interviewing the people who use the service about their experiences, and inspecting their records. • Interviewing staff on duty about their experiences working in the home. • Informal discussion with staff and other people who use the service. • Discussion with other care professionals involved with the service. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. • Assessing the AQAA (Annual Quality Assurance Assessment) which is an annual return which the registered persons have to return to the commission. Other evidence gathered since the previous inspection, such as notifications received from the home (e.g. regarding any incidents which occurred), were used to help form the judgements made in the report. What the service does well: The registered persons provide pleasant and homely accommodation at Woodside Farm. Significant renovation occurred before the home was registered in July 2007. The physical standards of the building meet the National Minimum Standards which were introduced in April 2002. Therefore the communal areas and bedrooms are spacious, and all bedrooms have ensuite facilities. Only a minority of homes for younger adults currently meet these standards as many were registered before April 2002. The registered persons and the staff team have achieved a significant amount in ensuring the home is functioning effectively in a short time. It cannot be underestimated the work required to set up a new home, recruit staff, assess and help people who use the service to settle in to their new home. The inspector was able to speak to two specialist nurses from the learning disabilities team, as well as a social worker and a care manager at the Department of Adult Social Care (social services). They were generally positive about how the often complex needs of people who use the service have been managed. One person using the service was described as being ‘happier and more settled than ever seen’ by one professional. People living in the home Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 Page 6 said they were happy living there and their care needs appear to have been met since they moved in. What has improved since the last inspection? What they could do better: 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. Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 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 Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information received by people living in the home regarding their rights and responsibilities is to a good standard. This ensures people who use the service should have appropriate information to be aware of their rights and responsibilities. Suitable assessment processes are also in place. EVIDENCE: The registered persons have developed a satisfactory statement of purpose and service user guide. The statement of purpose outlines what service the registered persons provide. A copy of this document needs to be placed in the home’s policy file. A summary of the statement of purpose, and other information regarding what service people who use the service can expect, is contained within the service user guide. Individualised copies of this document are contained within individual files. The registered manager said there is a copy of this document in each person’s bedroom, people’s representatives and relevant professionals have received a copy. Contact details regarding the Commission for Social Care Inspection need to be updated. The commission will inform the registered persons of these shortly as they are due to change. The registered provider has developed a suitable assessment policy and procedure. There is evidence people who use the service were appropriately assessed, before they moved in to the home. There is currently one vacancy at the home. The registered manager said staff believed it was important not to Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 Page 9 rush to fill the vacancy so somebody who was compatible with the other residents could be offered the placement. There is the opportunity for people being assessed for the service to visit before admission is arranged. A trial period is offered to people who use the service. Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Suitable information appears to be provided to assist staff to provide appropriate support to people living in the home. This helps to ensure people who use the service receive a good quality service. EVIDENCE: There is a copy of a care plan in each person’s file. Currently there is relevant information contained in several documents e.g. from the home, from the NHS etc. A more cohesive document will need to be developed over the next six months so appropriate information is more readily accessible. For example due to the complexity of people’s needs, specific interventions which are required should be recorded to ensure consistency. Care plans appear to be available to staff. Regular reviews are held with the multi disciplinary team. The inspector spoke to a care manager, a social worker and specialist nurses involved in the care of people living in the home. All felt that the four people who use the service had settled well in the home, particularly as the people accommodated can be viewed as having complex disabilities and can challenge services. Records of reviews / progress reports could be more thorough e.g. in the form of a Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 Page 11 monthly report which details a summary of events / any changes to the plan of care etc. Due to the nature of people’s disabilities and vulnerability, choice is restricted to people to varying degrees. However, from observation and discussion, it was evident that staff assist people who use the service to make choices where appropriate. Some of the people who use the service are diagnosed a being on the autistic spectrum as well as having other complex needs. Choices have to be clear and structured, and staff appeared to have a good understanding of this need. As care plans are developed care plans should clearly outline what support people who use the service need to make choices. Any risks and restrictions should be documented in the care plans. Where possible, evidence the multi disciplinary team has agreed this should be documented. Care staff look after the monies of some people who use the service. Cash held on behalf of people who use the service appears to be well looked after and accounted for. Appointeeship for people’s benefits is either held by DASC or the registered manager. Clear records are kept, and monies kept tallied with totals in records. Records regarding any bank / building society accounts held on behalf of people are to a satisfactory standard. Some restrictions are placed on people who use the service. These appear to be appropriate due to the vulnerability of people, and the risks associated with specific behaviours. However, the registered persons and at least senior staff should attend training regarding the Mental Capacity Act 2005. This legislation has significant implications regarding the restriction of choice and the management of finances. It would be helpful if all care staff had a basic understanding of this legislation to help them in their work. The Department of Adult Social Care (as well as other agencies) provides information and training regarding this matter. Information is available via the attached web link: http:/www.cornwall.gov.uk/index.cfm?articleid=37757 The registered provider has satisfactory policies regarding diversity and equality. There are currently no people who use the service from ethnic minorities, although the registered provider has stated they would be more than happy to accommodate people who use the service from other cultures. The local population is predominantly Cornish, and from ‘White-UK’ background. Issues regarding sexuality, and disability seem to be suitably addressed. Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have suitable opportunities to participate in the home and the wider community. Food provided is to a good standard. These measures ensure people who use the service can enjoy a varied lifestyle integrated into the wider community. EVIDENCE: People who use the service attend a range of day activities including attending voluntary work placements and colleges. Social trips are organised at the weekend or in the evening. People who use the service remain in contact with friends and relatives regularly, and they are encouraged to maintain contact via the telephone or post. Visiting arrangements are flexible. People who use the service said staff work with them in a way, which respects their privacy and dignity. Where possible people who use the service are encouraged to participate in household tasks and cooking. Interaction between other staff and people who use the service was observed to be positive. Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 Page 13 Staff try to facilitate choice and promoting independence, whilst ensuring people are not neglected and are cared for appropriately. There are some limitations to this as outlined in the previous sections. The home has several vehicles. This enables people who use the service to participate in the community. Through discussion with staff, people who use the service, and inspection of records, it is clear there are numerous opportunities for people to participate in a variety of activities. One person has requested assistance regarding religious observance, and the local minister visits the person when requested. The registered manager said holidays would be arranged for people using the service. Two of the people who use the service said they get involved in the preparation of meals. People can eat either on their own or share meals with others in the house. People living in the home said they enjoyed the food in the home, and there is always enough food available, for example, if they want a snack. Suitable records are maintained regarding food provided. Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care and health care support is to a good standard. Medication is managed to a good standard. Appropriate support with health and personal care ensures people who use the service are encouraged as much as possible to lead healthy lifestyles. EVIDENCE: People who use the service appear to receive suitable care and support from staff. The inspector expressed some concerns regarding staff training about awareness of autism, and dealing with aggressive behaviour. For example whether all staff have been trained appropriately in these areas. Although there is not clear documentation regarding this, the registered manager said all staff had received training regarding aggression and restraint. She said the home was awaiting certificates confirming recent attendance. The registered manager said people who use the service have access to local GP’s, dentists, chiropodists etc. The registered persons also employ a private consultant psychiatrist to assist them regarding people’s mental health. This person does link in with NHS staff, and the GP would have to make a decision regarding the authorisation of any changes to medication. The home also has access to an NHS consultant psychologist. There are records of medical interventions from external professionals, but recording needs to be clearer as it is of variable quality depending on the person concerned. Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 Page 15 Medication is stored securely, and dispensed via a ‘monitored dosage system’. Administration records seem to be kept appropriately and the storage of medication is to a good standard. Staff who administer medication appear to have received appropriate training e.g. from Boots. However the registered manager said three staff need to receive medication training, and this needs to be arranged as soon as possible. Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Suitable systems appear to be in place regarding how concerns and complaints are dealt with. However improvement is required to matters relating to adult protection. Improvement will ensure people who use the service can have confidence they have more protection against abusive practice. EVIDENCE: The registered provider has developed a complaints procedure, and a summary of this is in the service user guide. One ‘concern’ has been made to the service. Following discussion with the registered manager, this matter appears to have been dealt with appropriately. Records held regarding the matter were appropriate. The registered persons need to expand the adult protection procedure to state what action should be taken in the case of suspected abuse. In line with local authority protocols allegations need to be reported to the Department of Adult Social Care (DASC), who would take the lead role in deciding strategy. Organisations such as CSCI and the police (if necessary) would need to be informed. The policy does state staff would be suspended pending investigation. Details regarding local authority protocols can be found via the attached web link: http:/www.cornwall.gov.uk/index.cfm?articleid=14581 Staff also need to receive training to recognise signs of abuse, and what to do if they suspect abuse is occurring. Staff initially employed seem to have received this, but newer staff have not. DASC offers free training to care staff. Information regarding this can be found at: Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 Page 17 http:/www.cornwall.gov.uk/index.cfm?articleid=37715 The registered manager has a training package regarding abuse. However this is for another local authority. If the package is used, she needs to be clear there is no difference in policies and procedures advocated than in Cornwall. The registered manager reported one incident to DASC as suspected abuse (between two people using the service). This appears to have been investigated appropriately. However such matters must be reported to the commission under regulation 37 of the Care Homes Regulations 2001. No ex members of staff have needed to be reported to the authorities to request them being included on the Protection of Vulnerable Adults list. The Commission for Social Care Inspection is concerned regarding pre employment checks completed on staff. This matter is referred to in more detail in the ‘staffing’ section. Failure to deal with this matter appropriately could put people who use the service at risk of abuse. Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Woodside Farmhouse provides a pleasant, homely and clean environment for people who live there. EVIDENCE: The building was inspected. The building was renovated prior to the home opening in Summer 2007. The home offers a pleasant and homely environment for people who use the service. The building is divided into two ‘flats’ so each flat has its own lounge, and kitchen. The downstairs part of the home has a larger kitchen and a dining room which enables all people living in the home to eat together when they choose. The home was clean and hygienic on the day of the inspection. Suitable cleaning routines are in place. Bedrooms are pleasantly decorated according to individual tastes. All bedrooms meet the standards outlined in the 2002 National Minimum Standards. For example all have ensuite facilities, and bedrooms can accommodate a double bed. Furnishings in bedrooms are appropriate. Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 Page 19 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels appear to meet the needs of people who use the service. However recruitment practices and training require improvement. This will ensure staff employed are checked as fit to work with the vulnerable, and they are subsequently appropriately trained to meet the needs of people living in the home. EVIDENCE: On the day of the inspection there were the following numbers of staff on duty: • Three staff on duty from 07:30 to 15:00 • Two staff on duty from 08:00 to 16:00 • Five staff on duty from14:30 to 22:00 • The registered manager and the deputy manager were also on duty during the day. • Two waking night staff and one member of the evening staff slept in. Staffing levels on other days were also similar. The inspector read a suitable equal opportunities policy regarding staff recruitment and selection and this seemed satisfactory. The inspector observed recruitment and personnel information kept on staff files. In total the records of twelve staff were inspected. All staff files contained a full employment history and a statement of the person’s mental and physical health. However: Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 Page 20 • • • • Two references were not obtained for all staff. It is of concern at least three staff appeared to not have any references obtained, although the registered manager said she had tried to obtain these. Although all staff appear to have had a Protection of Vulnerable Adults check (POVA First) check (It is a legal requirement this check is obtained to ascertain people employed are not considered unfit to work with the vulnerable), record regarding this need improvement as it took some time to confirm these checks had occurred. Three staff (who commenced employment between September and November 2007) did not have a Criminal Record Bureau (CRB) check. A CRB check is required by law to check that staff do not have any criminal convictions which should prevent them from working with vulnerable people. The registered manager confirmed these checks had occurred, but the umbrella body or post office had lost the disclosures. The manager said these staff were constantly supervised, and this would continue until the disclosures were returned. The majority of staff did not have evidence on file regarding proof of their identity (however this information must have been seen by the registered persons in order for a CRB check to be obtained.) The Commission for Social Care Inspection was concerned that an ex member of staff had been employed, who the commission was aware has been referred to the POVA list and the Nurses and Midwifery Council. This person had worked some shifts including nights at the home, but the registered manager said the person is no longer employed. If appropriate references had been taken up on this person, it would have been clear to the registered persons that the staff member should not have been employed to work in the care home. Staff induction and training records were inspected. Training for staff recruited before the home opened was to a high standard. For example staff received training in manual handling, food hygiene, fire awareness, first aid, infection control and medication. Staff also received training regarding key principles of care, physical intervention and person centred care. Induction also seemed to a good standard. However some of these staff have left and have subsequently been replaced. These staff appear not to have not completed all training required by the regulations. For example: 1. Some staff do not have training required by law (fire, food, first aid, manual handling and infection control. 2. Some staff involved in the administration of medication having appropriate training. 3. Induction checklists for some staff have not been completed in full for staff recruited from Autumn 2007. 4. Staff need to receive training regarding the awareness of autism. Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 Page 21 The registered manager said all staff have now received training regarding deescalation of violent situations, ‘Breakaway’ techniques and restraint. She said staff that commenced employment before the home opened received this during their induction period. Records also show this. She said staff that commenced employment since have now completed the training and they are awaiting certificates. The registered persons are subsequently required to organise the training. The AQAA (Annual Quality Assurance Assessment) submitted by the registered persons dated 16/10/2007 states three of the permanent staff and one of the bank staff has a National Vocational Qualification in care. This represents only 14 of permanent staff. The registered persons need to develop their approach to ensuring at the very least 50 of staff have a national vocational qualification in care. It may be more appropriate that management consider staff working towards achieving an LDAF / LDQ (Learning Disabilities Awards Framework / Learning Disability Qualification). Information regarding this can be obtained via ‘Skills for Care’ or via the following web link: http:/www.ldaf.org.uk/index.html?LDAF_Session=d7e8593b5e7bcef99cea980 2a0d4fec2 Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management systems need to be improved to ensure staffing and quality systems are developed. EVIDENCE: The registered provider is Meadowbank Care (St Austell) Ltd. The responsible individual Mr Peter McNeil lives in Cornwall and is involved in the management of the scheme. A registered manager Ms Sharon Westwood has been appointed by the registered provider, and has been registered with the commission. Ms Westwood is also the Director of Care for the registered provider. The registered provider is required to carry out an unannounced visit to the home on a monthly basis under regulation 26 of the Care Homes Regulations 2001. These visits have been completed and copies of the reports have been sent to CSCI for the period from September 2007. The reports sent to CSCI seem to be satisfactory. Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 Page 23 The registered persons have achieved a lot since setting up the home in July 2007, and the home appears to operate quite smoothly. The registered manager appears to be suitably competent, skilled and knowledgeable to manage the home. The commission is however concerned about some aspects of recruitment practices at the home as outlined in the last section of the report. Although current standards have not resulted in the commission becoming aware of any poor practice, the likelihood of potential poor practice or abuse occurring could be increased, if unsuitable staff are employed (i.e. due to inadequate pre employment checks). Statutory requirements have been made regarding these issues, and action will be monitored to ensure compliance is achieved. The registered persons must also ensure that any events, under the regulations are notified to the commission. These are clearly outlined in regulation 37 of the Care Homes Regulations 2001. The commission does not appear to have received any notifications regarding this service since it opened. Staff can always ring up the commission beforehand if they are unsure if something is reportable. The registered persons approach to quality assurance needs improvement. The commission has received the Annual Quality Assurance Assessment (AQAA) from the registered persons. This has been completed to a satisfactory standard. There is currently no quality assurance policy at the home, and this needs to be developed. Procedures could include how the registered persons will achieve compliance with issues raised in this report for example through an annual development plan. There could also be a proactive system in future to check various systems are operating smoothly e.g. to ensure compliance with the regulations. Standards of care are however generally positive, and people the inspector spoke to all said they were happy living in the home. The registered persons have a suitable health and safety policy. Most health and safety records are satisfactory. For example there are suitable records of the testing of fire equipment, the central heating system, the electrical hardwire circuit and portable electrical appliances. Accident / incident records are suitably kept, although some incidents should have been reported to the commission. As stated above some of these incidents should have been reported to the commission. Records of water temperatures are maintained (e.g. to prevent the risk of scalding). Health and safety risk assessments appear satisfactory. There is a suitable fire risk assessment. Suitable insurance cover appears to be in place. A requirement regarding improving health and safety training has been made. Shortfalls regarding this matter are outlined in the previous section of this report. Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 3 34 1 35 2 36 X 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 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 Page 25 NA 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 YA23 Regulation 10, 12, 13(6) Requirement The registered persons need to improve procedures and practices to help prevent people who use the service from abuse. For example: 1. The adult protection policy should be in line with local authority protocols. Please forward a copy of this policy within the timescale set. 2. All staff need to receive training regarding recognising abuse and what to do if they suspect abuse occurring. These measures will ensure appropriate procedures and training are in place to alert management and external agencies regarding any allegations of abuse should they occur. The registered persons must develop an appropriate policy and procedure to ensure at least 50 of staff have a national vocational qualification in care / learning disability qualification DS0000070376.V352930.R02.S.doc Timescale for action 01/08/08 2 YA32 18 01/08/08 Woodside Farmhouse Version 5.2 Page 26 3 YA34 YA37 7, 9, 19 Schedule 2, Schedule 4 (LDQ). This will ensure at least 50 of staff have an appropriate professional qualification in care. The registered provider must 01/08/08 ensure all staff have recruitment checks required by law. This must include: • Documentation outlined in Schedule 4 of the Care Homes Regulations 2001 such as two written references etc. • Staff receiving a POVA First check before they commence employment • A Criminal Records Bureau check which must be obtained before the member of staff carries out unsupervised care of people who use the service. This will help to ensure staff are fit to work in a care home setting with vulnerable people. 01/09/08 The registered persons must ensure staff receive appropriate training according to the law and to meet the needs of people who use the service. This needs to include: • Training regarding fire, manual handling, food handling, infection control and first aid. Training regarding fire and first aid (to ensure satisfactory first aid cover) must be prioritised and should be delivered no later than in the next three months i.e. 01/05/08. • Training so staff have an awareness of autistic spectrum disorders. • Training to handle medication for appropriate DS0000070376.V352930.R02.S.doc Version 5.2 Page 27 4 YA35 YA37 7, 9, 18 Woodside Farmhouse • • staff must be delivered in the next three months 01/05/08 Training regarding minimising the risk of violence, breakaway and restraint (NAPI approved) for all staff involved in this type of intervention if any staff have not received this training. Appropriate updates must be completed. If necessary, this training must be delivered in the next three months i.e. 01/05/08. Induction training for staff is completed outlined in the induction checklist. 5. YA37 7, 9, 37 6. YA39 24 Staff must receive all training by no later than 01/09/08. The registered persons must ensure any new staff complete required training no later than six months after the date of appointment. Suitable training will ensure people who use the service are supported by staff who are appropriately trained to meet their needs, according to legal requirements. Any events which are notifiable under regulation 37 (e.g. events adversely affecting the wellbeing or safety of any service user, allegation of misconduct by the registered person or any person who works at the home) must be notified to the commission and confirmed in writing The registered persons must set up an effective quality assurance system. 16/01/08 01/08/08 Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 Page 28 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 YA7 YA9 Good Practice Recommendations Key staff should attend training regarding the Mental Capacity Act 2005 Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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. Extracts may not be used or reproduced without the express permission of CSCI Woodside Farmhouse DS0000070376.V352930.R02.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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