Inspection on 31/10/06 for Wray Court (3)

This inspection was carried out on 31st October 2006.

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 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

Wray Court (3) 05/12/05

Wray Court (3) 15/08/05

Wray Court (3) 18/01/05

Wray Court (3) 27/07/04

Wray Court (3) 09/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Wray Court (3 ) 3 Wray Court London N4 3QS Lead Inspector Ms Edi O’Farrell Unannounced Inspection 31 October 2006 10:30 st Wray Court (3 ) DS0000031155.V288051.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 Wray Court (3 ) DS0000031155.V288051.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. Wray Court (3 ) DS0000031155.V288051.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wray Court (3 ) Address 3 Wray Court London N4 3QS 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) 020 7281 4464 020 7272 4768 andy.washington@islington.gov.uk Islington Social Services Andrew Washington Care Home 6 Category(ies) of Learning disability (6), Physical disability (6) registration, with number of places Wray Court (3 ) DS0000031155.V288051.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 05/12/2005 Brief Description of the Service: Wray Court offers a six-place, building based, respite (planned short stays) and emergency, service for adults with learning and/or physical disabilities. The London Borough of Islington operates the service and access is always via an assessment by Islington Learning Disability Partnership. Prospective service users have to be the financial responsibility of the borough, and to be assessed as eligible for community care services. The home currently provides respite services to approximately 25 people. Stays are planned so as to enable adults with learning disabilities to continue living with their families. As this supports informal carers, both they and the people with learning disabilities are the service users. The service has very recently moved from Wray Court to 28 King Henry’s Walk, N1. This is a temporary move, whilst building upgrading is carried out. The service is co-located with another Islington learning disability home, Orchard Close. The registered manager of that home is responsible for both services whilst they are in their temporary accommodation. Two assistant managers have specific responsibility for the Wray Court service. King Henry’s Walk has full disabled access, and each person has a single room. Lounges, a small kitchen/dinner, bathrooms and toilets are shared. Personal care is provided on a 24-hour basis, with staffing levels being based on the assessed needs and numbers of the service users in on any one day or night. Charges are £50.40 per day for people aged under 25 and 62.35 per day for those over age 25. Wray Court (3 ) DS0000031155.V288051.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this, unannounced, inspection was carried out on a weekday from mid morning to mid afternoon. It lasted just over five hours. During this time records were examined and discussed with the two assistant managers. Discussions were also held with the manager, and with their line manager, who carries out monthly monitoring visits. One, very new, member of staff was interviewed specifically about how the service handled recruitment and induction. The care of two service users was looked at in detail. This included talking to one of the service users, and in the other case a relative. The latter was by phone prior to the visit. A variety of records, such as care plans, daily logs, and accident records, were looked at and cross-referenced. This was to see if the service was meeting identified needs. Prior to the site visit all information held at our office had been reviewed. This included the monthly reports and serious incident reports. Pre- inspection information provided by the manager was included in this review. Easy read surveys were sent to 20 service users where the pre-inspection information identified English as a first language. Seven were returned. Where other first languages were identified, such as Vietnamese and Spanish, a translated version of the survey was sent. One of these was returned. The vast majority of the forms were completed either by parents or with their help. Some service users, and their parents, felt that the survey was, in parts, not suitable for respite care users, so not all questions were answered, e.g. choice of home. All key standards were assessed. Following the site visit we sent a form so that the home could let us know how they felt the inspection went. What the service does well: A relative said ‘our keyworker is excellent – very through and organised’. service user said ‘ choice is good’ and ‘they treat me like an adult’. Our findings during this inspection support these views. A Independence and choice are encouraged, as is risk taking. Activities and outings are organised on a regular basis. They are based on the interests and wishes of the service users. Service users are supported to continue attending day centres, colleges, and clubs during their stays. This all means that there is as little disruption to they lives as possible, while they are away from home. Wray Court (3 ) DS0000031155.V288051.R02.S.doc Version 5.2 Page 6 Equality and diversity are taken seriously. This is important as the service is provided to residents of the London Borough of Islington, which has a culturally diverse population. Staff are recruited in a transparent and fair way. Service users’ cultural needs are identified in care plans, respected and met. Care plans contained were good examples of a social care approach to health related conditions. These concentrated on the effect on the daily life of service users. There was also evidence of the principles of ‘Valuing People’ being applied to care planning. For example, in one care plan, ‘His care and support is planned around this to minimise risk and at the same time to provide him with the opportunity to maximise his capabilities and skills’. These approaches are excellent as concentrate on the service user’s strengths, rather than weaknesses. This can make a big difference to quality of life. What has improved since the last inspection? What they could do better: Some thought needs to be given to how, and where, important information is recorded. For example, changes to prescribed medication. This is so that staff have a clear picture of the overall needs of each service users. There needs to be greater consistency in what is recorded on a daily basis. Best practice for services for people with learning disabilities is for a ‘person centred’ approach to be taken. This means recording how such things as activities have gone, as well as that they happened. Wherever possible service users need to be involved in the writing of these reports. Managers need to regularly look at things like the daily reports. This is to make sure that they pick up on important information, such as cuts and bruises. Greater thought and attention needs to be given to the protection of service users from potential abuse. l The recording of complaints and concerns where they are resolved locally and quickly needs to be improved. Concerns and complaints, no matter how small, are an important way that managers can pick up trends. Acting on these can lead to service improvements. Wray Court (3 ) DS0000031155.V288051.R02.S.doc Version 5.2 Page 7 There needs to be a system of regularly asking service users, their families, and other ‘stakeholders’, such as social workers, what they think of the service. This needs to include how they think it could be improved. 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. Wray Court (3 ) DS0000031155.V288051.R02.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 Wray Court (3 ) DS0000031155.V288051.R02.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ needs are assessed, and the service offered supports both service users and their carers. EVIDENCE: As a respite service the ‘users’ are both the people with learning disabilities and their informal carers. Members of Islington Learning Disability Partnership carry out the assessments. These are multi-disciplinary where necessary. A report is then considered by the eligibility panel, which the Responsible Individual, who line manages the home’s manager, is a member of. A copy of the assessment is then forwarded to the home. Copies were seen on the files examined, and in the two case files looked at the identified needs were clearly stated. There was evidence of service users not being accepted, because their needs could not be met. Where emergency admissions had to be made as much information as possible was gather, as soon as possible following admission. Risk assessed was always carried out prior to such admissions. Wray Court (3 ) DS0000031155.V288051.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. Service users’ needs are reflected in their care plans. They are supported to take risks within the context of their community care plan. EVIDENCE: Two case files were examined in detail. In one case the service user was in the home during the site visit, they said, ‘choice is good’ and ‘they treat me like an adult’. There was an emphasis in the care plan on encouraging independence, such as staff supporting the service user to make their own breakfast and snacks. Their likes and dislikes were recorded in the care plan, and the daily records showed that these were, in the main, respected. There was a very good risk assessment, which had been done jointly by the service user and staff. This covered going to a fun fair, and going on specific rides. On the day of the trip the morning shift had noted in the daily report that the service user had gone off to the fun fair. This had not been followed Wray Court (3 ) DS0000031155.V288051.R02.S.doc Version 5.2 Page 11 through by the afternoon shift, i.e. there was no mention of how the trip had gone, if it had been enjoyed, or if the risk assessment had proved appropriate. This was discussed with the assistant manager who had gone to the funfair with the service user. Review and reflection is as important in care planning as assessment, and can lead to service improvements. In this case the home could not demonstrate that this had been the case. This was a lost opportunity, particularly as it would have been possible for the service user to be involved in the writing of the report. This lack of follow through is covered further later in this report. All survey responses were positive about choice. Wray Court (3 ) DS0000031155.V288051.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. Service users are encouraged to continue their day-to-day activities whilst they are receiving respite care. EVIDENCE: Both of the care plans looked at included details of the usual lifestyle of the service users. The service user spoken to gave examples of going bowling, swimming and ice skating. They said that the only thing that could make the service better would be going out even more. Many of the service users attend day centres, collages, and clubs. This continues whilst they are in respite care. On the survey form one relative/service user asked if staff could continue the home routine whilst the service user was in respite. ‘Different routine takes longer time to adjust when return home’. This was discussed with the Wray Court (3 ) DS0000031155.V288051.R02.S.doc Version 5.2 Page 13 assistant managers who reported that some service users acted very differently when in respite. They stated that they worked closely with families to negotiate following through home routines, and where routines were not working this would always be discussed with parents. It was not possible to check the care plan of this particular service user, as the survey did not identify them. However in one of the case files looked at there was a stated preference, by both the family and the service user, for a nightly bath. The daily report showed that in recent stays this had been changed to a shower. There was no evidence to show that this change had been discussed with the family. This is covered further in the next section of this report. As stated earlier in this report the service had very recently moved into temporary accommodation. They were sharing the building with another home, and, as expected, there were some teething problems. The service user spoken to had already raised access to the washing machine as an issue. They felt that the other home was being given priority. Staff had agreed to discuss this in the joint staff meeting, which was being held the following day. This included suggesting that the service user join the meeting for that particular discussion. If this did occur it would be an excellent example of using everyday events to demonstrate rights and responsibilities. Menus were varied with a vegetarian choice at each main meal. The records showed that many service users took this option. This was discussed with the manager and briefly with the chef. This was to establish if this was an active choice or was due to budget restraints. They reported that it was the former. Religious and cultural observance regarding food was detailed in the care plans seen. The service user spoken to, who was Muslim, confirmed that their wishes were followed. They gave examples of where they had been offered alternatives to pork, and others where Halal meat had been used. Wray Court (3 ) DS0000031155.V288051.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 adequate. This judgement has been made using available evidence including a visit to this service. Service users’ health and personal care needs are identified, and how they should be met is based on the principles of ‘Valuing People’. These values are not always followed through in the care planning and recording systems. EVIDENCE: In one of the files examined there was a very good explanation of the service user’s medical condition and the effects on his daily life. ‘His care and support is planned around this to minimise risk and at the same time to afford him dignity and respect in order to provide him with the opportunity to maximise his capabilities and skills.’ This was a good example of the principles of ‘Valuing People’ being incorporated into a care plan. There were detailed risk assessments relating to his medical conditions. For example, if assisting him with a bath to let other staff know so that they could be available to help if needed. There were also details of his ways of communicating, such as. ‘may use objects of reference to express his needs’. This was all excellent. Wray Court (3 ) DS0000031155.V288051.R02.S.doc Version 5.2 Page 15 However, the personal care assessment stated the preference of his carers for him to have a bath in the evening, as it relaxed him. The risk assessment also stated that he would choose to have a bath. The daily log showed that he was having showers in the evening. This was discussed with the assistant managers, who agreed that the reviews of some care plans were overdue. This is Requirement 1. Daily records included references to service users’ moods, and in some cases, how they had responded to specific activities. This was not consistent, as in the trip to the fun fare. There was also no reference to the above service user having shown a particular preference for a shower rather than a bath. In order to be useful documents, rather than merely a paper exercise daily logs need to be comprehensive and reflective. Wherever possible service users should be involved in the writing of the records. This is Requirement 2. There was no medication held in the home during the site visit. Several medication administration (MAR) charts were examined, one of which had a label stuck over a previous prescription. The manager was reminded that this was unacceptable practice. This is Requirement 3. The MAR charts were compared to the message book, and daily reports. In one case the chemist had supplied the wrong strength of medication. Staff had taken appropriate action, which they had noted in the message book, but not in the daily report. In another case a change of medication had been noted in both, but in a third case was again only noted in the message book. This system was discussed with the assistant managers, who felt that such changes needed to be recorded in the message book. This implied that they did not feel confident that staff would read daily records to find out important changes to such things as medication. The current recording system needs to be reviewed so that all changes to personal and healthcare support are recorded in the same place. This is Requirement 4. Since the last inspection there had been an incident where one service user had taken another’s medication, as a staff member had left it on the table. Staff had acted appropriately in contacting the GP and followed their advice. Management had followed up the incident correctly and reminded staff of appropriate procedure. No harm had come to the service user. The returned surveys indicated satisfaction with the provision of personal and health care, apart from one parent who felt that personal care could sometimes be better. This was discussed with the assistant managers, who were advised to contact this parent to discuss this concern. Wray Court (3 ) DS0000031155.V288051.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. Service users are not fully protected by the home’s handling of concerns and unexplained accidents. EVIDENCE: The pre-inspection information provided by the home stated that there had been no complaints during the last 12 months. This was unusual in any care home, but particularly so in a respite care unit. We would expect to see common complaints from families about missing clothes, and unexplained marks or bruises. The above was discussed with management during the site visit. They stated that there was a formal three-stage procedure. There was an emphasis within this procedure on local resolution. They provided evidence of several recent complaints about missing clothing that had been almost immediately resolved by staff. This evidence was in the message book, rather than in a concerns/complaints log. It was also not, generally, recorded in the daily report, primarily because service users had already gone home before their relative rang the home with the concern/complaint. Concerns and complaints are a valuable source of feedback to services. Monitoring by management can lead to service improvements. The home must keep a record of all complaints, including where immediate local resolution is achieved. This is Requirement 5. Wray Court (3 ) DS0000031155.V288051.R02.S.doc Version 5.2 Page 17 Daily reports were seen that should have been followed up by management. In one case staff had noted a small scratch on a service user, and in another the service user had raised a health issue with staff, that could have been abuse related. In both cases staff had taken the trouble to report these, but there was no evidence of any follow up by managers. In addition one relative reported that a service user had returned home with a graze on his arm. When the reports for this stay, along with the accident/incident records, were checked no reference to this was found. The managers were advised to contact the relative to follow this up. The respite service is provided to a very vulnerable group of adults with learning disabilities. All reported injuries and relevant health issues must be followed up and outcomes recorded. Where necessary adult protection referrals must be made. This is Requirement 6. Information held on file in our office showed that there had been two adult protection investigations prior to the last inspection. One of these had not been resolved at that time, so the outcome was discussed during this visit. The independent investigator had arrived at a conclusion that the injury was self-inflicted due to the service user spending a lot of time on the floor. The service user was no longer using this service. Wray Court (3 ) DS0000031155.V288051.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 adequate. This judgement has been made using available evidence including a visit to this service. The current environment meets the needs of the service users as far as possible in temporary accommodation. EVIDENCE: The service was housed temporarily at another home, King Henry’s Walk (KHW), whilst Wray Court was being refurbished. They had moved there in mid October, and expected to move back in February 2007. A Requirement had been set at the previous inspection that Wray Court be redecorated, with a timescale of 31/03/07. This Requirement has not been brought forward in this report as it was obviously already being acted upon. A minor variation had been agreed for KHW to accommodate, on a temporary basis, Wray Court and another home, Orchard Close. Wray Court (3 ) DS0000031155.V288051.R02.S.doc Version 5.2 Page 19 An initial tour of the building was undertaken accompanied by the manager. There was ‘very hot water’ signs above all sinks. The manager of Orchard Close had put these up because when they moved in the boiler setting, which was in the day centre next door, was too hot. This had since been adjusted, but the signs had been left up as a precaution. Whilst water temperature had been too hot daily temperature checks had been undertaken. KHW was purpose built for wheelchair users. It had single bedrooms and appropriate communal space. All areas were clean, tidy, and hygienic. As Wray court had only recently moved in some furniture, such as clothes rails, still had to be purchased. It was not clear why these had not been purchased prior to the home moving in. There were some teething problems, but not to the level that had been expected. The use of bathrooms, toilets and showers were meeting the needs of service users. The home was clean and hygienic. The temporary move meant that some facilities, such as sensory stimulation equipment were not available. Also pictorial signs, to assist service users to identify various rooms, had not yet been put up. As these matters were being dealt with no Requirements have been set. Wray Court (3 ) DS0000031155.V288051.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user benefit from an effective staff team. EVIDENCE: There was only one relative survey returned but relatives also assisted in completing most of the service user surveys. They were generally very happy with the service. ‘Our keyworker is excellent – very thorough and organised’. The last inspection report had three, restated, Requirement under this outcome heading. These covered the use of agency staff, training profiles, and supervision. We had a meeting with responsible individual prior to the site visit and she informed us that recruitment has now gone ahead. This was supported by information supplied in the pre inspection questionnaire. Staffing levels were varied dependent on the needs of the service users in on any one day. Staff were observed indirectly during the site visit. They had a good relationship with the one service user in on that day. Daily logs showed that staff were aware of service users’ needs. Wray Court (3 ) DS0000031155.V288051.R02.S.doc Version 5.2 Page 21 We visited the central human resource department of Islington Council earlier in the year, to look at staff files. At that stage there was a hold on Wray Court recruitment, as the plans for temporary relocation had not been finalised. Files for two other homes were examined. They demonstrated robust selection procedures, within an equal opportunities, and diversity, framework. There was no reason to suppose that the high standard would not be applied to Wray Court. A new member of staff who had started the previous week was interviewed during the site visit. She had relevant previous work experience. She confirmed that she had not yet giving medication but had observed other staff. She described the recruitment process. This had included a written test of reading through a description of someone and then doing a care plan. There had been a three person interview panel, with all asking questions and taking notes. They had taken up two references and a full CRB check prior to her starting. She had been supplied with the Islington induction pack, and was shadowing other staff for a two-week period. Whilst she had not seen some of the policies and procedures she was aware of the most important ones, such as adult protection, and how to find out about others. Staff training records were examined as there had been a Requirement made at the last inspection. The training plan did not have the name of the service added. It was being used as record of training, rather than as a plan. This was discussed with one of the assistant managers and agreed as work in progress so no Requirement has been set. Supervision records were also looked at as there had been a Requirement made at the previous inspection. There had been a marked improvement and the standard of at least six times a year is now being met. Records showed that individual sessions are between 8 and 10 times a year. Wray Court (3 ) DS0000031155.V288051.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. There was a lack of management follow through of important issues relating to the protection of service users. The provider had recognised that clear managerial responsibility was needed during the temporary relocation of the service. This should impact positively on the service and provide capacity to improve. EVIDENCE: There were several indicators to support the above judgement. These have been detailed in earlier section of this report, but could be summarised as a lack of management follow through, and in-house audit. For example, if a manager was not confident that staff read service user’s daily records, then action should have been taken to ensure they did so. Equally it seemed that managers did not always read these records, or if they did that they did not act on what they read. Refer to Requirement 6. Wray Court (3 ) DS0000031155.V288051.R02.S.doc Version 5.2 Page 23 The management arrangements for the service were in the process of being changed. From the day following the site visit the Registered Manager of Orchard Close was to become the manager of both services. Three Assistant Managers would support her in managing the services. Two of these would hold specific responsibility for the respite service. Management at the Orchard Close inspection earlier in the year was judged as good. The new arrangements should impact positively on the respite service. There was a system of annual service unit planning. Senior management had recently reviewed the plan. This system did not include gaining the views of service users and relatives. We were informed that there was a quality assurance system, which included surveys. This was due to be implemented soon. This is Requirement 7. The Responsible Individual had sent us monthly Regulation 26 reports, and was at the home, carrying out a visit, during the inspection. The report, which was received the following day, clearly identified health and safety issues, such as the water temperature and fire safety. As this was work in progress no Requirements have been set. Wray Court (3 ) DS0000031155.V288051.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 2 X 2 X X 3 X Wray Court (3 ) DS0000031155.V288051.R02.S.doc Version 5.2 Page 25 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 YA18 Regulation 15 (2) (b) Requirement The Registered Person must ensure that care plans are regularly reviewed, so that they reflect actual practice, and preferences. The Registered Person must ensure that daily records accurately reflect the service provided, and how this has impacted upon the service user. Wherever possible the service user should be involved in the writing of the reports. The Registered Person must ensure that correct procedure is always followed in relation to MAR charts. Labels must not be stuck over previous prescriptions. The Registered Person must review the current recording system for changes in personal and healthcare support. This particularly relates to medication changes. There must be a comprehensive daily record of each service users’ stay. The Registered Person must keep a record of all complaints/concerns, including DS0000031155.V288051.R02.S.doc Timescale for action 31/12/06 2 YA19 12 31/12/06 3 YA20 13 (2) 30/11/06 4 YA20 13 (2) 31/12/06 5 YA22 22 31/12/06 Wray Court (3 ) Version 5.2 Page 26 6 YA23 YA37 13 (6) 7 YA39 24 where there is speedy local resolution. The Registered Person must ensure that all reported marks, such as scratches and bruises, are followed up. Also that reported health problems that could be abuse related are followed up. The adult protection procedure must be complied with. The Registered Person must ensure that there is an effective quality assurance system in place. This must include seeking the views of service users, their families, and other stakeholders. 30/11/06 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wray Court (3 ) DS0000031155.V288051.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Camden Local Office Centro 4 20-23 Mandela Street London NW1 0DU 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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