Care Home: 1 Wharf Close

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What the care home does well Visitors to the home are made to feel welcome. People living at the home are enabled and supported to maintain friendships and relationships with others. Food provided to residents is of a good quality and people indicated that they enjoy the meals provided. There is a varied menu which meets peoples needs. Support staff were observed to have a good rapport and positive relationship with residents. People were observed to be relaxed and to enjoy staff member’s company.1 Wharf CloseDS0000018081.V377563.R01.S.docVersion 5.3A plan of care is available for each person and this was seen to be detailed and comprehensive, identifying people’s care needs and how these are to be met by staff. Risks are identified for all areas of assessed risk and includes guidelines for staff so as to minimise the risks and promote positive outcomes for the people at Wharf Close. There is good evidence to show that the healthcare needs of people within the home are monitored by the staff team and where appropriate, interventions from healthcare professionals and services are provided. People at the home are supported to lead an active life, to undertake a variety of activities which meet their individual needs according to their personal preferences, likes and dislikes. Staff working at the home are experienced in working with people who have a learning disability and have worked for the organisation for some considerable time. What has improved since the last inspection? Medication storage facilities within the home are now appropriate so as to ensure that medication is stored at the correct temperature. Since the last key inspection residents vanity units have been replaced in their bedroom. Robust recruitment procedures are now in place at Wharf Close so as to ensure people’s safety and wellbeing. Training opportunities for staff have now improved so as to ensure positive outcomes for people living at the home. Key inspection report CARE HOME ADULTS 18-65 1 Wharf Close 1 Wharf Close Goldingham Farm Estate Stanford Le Hope Essex SS17 0EJ Lead Inspector Michelle Love Key Unannounced Inspection 16th September 2009 12:35 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service 1 Wharf Close Address 1 Wharf Close Goldingham Farm Estate Stanford Le Hope Essex SS17 0EJ 01375 360789 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) maggie.prakash@familymosaic.co.uk www.familymosaic.co.uk Family Mosaic Manimakalai Prakash Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning Disability - Code LD The maximum number of service users who can be accommodated is: 4 23rd September 2008 Date of last inspection Brief Description of the Service: Wharf Close provides personal care and accommodation for four adults with a learning disability. The home’s facilities include one large living/dining area, four single bedrooms and one bathroom. The home is situated in a quiet cul-de-sac in a residential area close to the town centre of Stanford-le-Hope. There is a pleasant garden to the rear of the property and adequate car parking facilities. Public transport runs close by the home and all amenities are in close proximity. Service users within the home are encouraged to access leisure pursuits and community facilities. The home has its own vehicle available for use by the residents. Family Mosaic (formerly New Essex Housing Association and Mosaic Homes) manages the home. The Service User Guide and Statement of Purpose are available and are updated as required. The residents and their representatives are provided with this information and it is displayed for reference along with current inspection 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 5 reports. At the time of this report the homes fees for current service users were not ascertained. The current scale of weekly charges at the home’s last inspection for residents is between £1050.00 and £1116.10. Additional charges are made for aromatherapy, chiropody, hairdressing, toiletries, personal clothing, activities and for the lease vehicle. 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The Quality Rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced key inspection. The visit took place over two days by one inspector and lasted a total of 6 hours, with all key standards inspected. Progress against previous requirements from the last key inspection was also inspected. Prior to this inspection, the manager had submitted an Annual Quality Assurance Assessment (AQAA). This is a self assessment document, required by law, detailing what the home does well, what could be done better and what needs improving. Information given in this document has been incorporated into this report. As part of the process a number of records relating to people who live at the home, support staff and the general running of the home were examined. Additionally a full tour of the premises was undertaken and 4 members of staff were spoken with and their comments are used throughout the main text of the report. We recognise that the people living at Wharf Close have a range of complex needs, including specific communication difficulties. As a result of this, observations of their interactions with staff and observing non verbal signs of communication were also monitored and recorded within the main text of the report. The manager and other members of the staff team assisted the inspector on both days of the inspection. Feedback on the inspection findings, were given as a summary at the end of the second day of inspection. The opportunity for discussion and/or clarification was given. What the service does well: Visitors to the home are made to feel welcome. People living at the home are enabled and supported to maintain friendships and relationships with others. Food provided to residents is of a good quality and people indicated that they enjoy the meals provided. There is a varied menu which meets peoples needs. Support staff were observed to have a good rapport and positive relationship with residents. People were observed to be relaxed and to enjoy staff member’s company. 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 7 A plan of care is available for each person and this was seen to be detailed and comprehensive, identifying people’s care needs and how these are to be met by staff. Risks are identified for all areas of assessed risk and includes guidelines for staff so as to minimise the risks and promote positive outcomes for the people at Wharf Close. There is good evidence to show that the healthcare needs of people within the home are monitored by the staff team and where appropriate, interventions from healthcare professionals and services are provided. People at the home are supported to lead an active life, to undertake a variety of activities which meet their individual needs according to their personal preferences, likes and dislikes. Staff working at the home are experienced in working with people who have a learning disability and have worked for the organisation for some considerable time. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 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 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective people can expect to be assessed prior to admission and assured that their care needs will be met. EVIDENCE: No changes have been made to the services pre admission assessment documentation or assessment process since the last key inspection. As highlighted at previous inspections to the home there is a formal pre admission assessment format in place, so as to ensure that the management and staff team are able to meet the prospective persons needs. In addition to the formal assessment process, supplementary information is sought from the individual person’s placing authority. The manager confirmed that no residents have been admitted to the home since 2004. 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be sure they will have an individual plan of care, identifying their care needs and how these will be met. EVIDENCE: There is a formal care planning system in place so as to help staff to identify the persons care needs and to specify how these are to be met by support staff. As part of this inspection the care files for 2 people were examined in full. Records showed that each person had a plan of care which was comprehensive, detailed and person centred. Each of the care files were easy to follow and included information relating to the person’s specific care requirements and the action taken by support staff to meet the assessed needs 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 11 of the individual. In addition specific information relating to their personal preferences, likes and dislikes were recorded. Records showed that the plan of care is seen as a ‘working document’ by the management team of the home, and where there are changes to the person’s care needs, the care plan is updated and reviewed so as to ensure that the information accurately reflects the needs of the individual person. For example since the last inspection concerns had been raised in relation to one person being regularly targeted by other people they live with and the impact this has had. Records showed that consideration has been made to look at how the person can be best supported to live at Wharf Close without being at risk of physical injury and emotional distress by others e.g. the seating arrangements for meal times and when the person accesses the community using the home’s lease vehicle have been reviewed so as to ensure the person’s safety and wellbeing. Records showed that in June 2009 an Individual Programme Plan Review took place and this involved the resident, family representative, manager, support staff, care manager and independent advocate. On inspection of the review documentation, areas discussed included health and welfare, social activities, finances, communication, education, medication, family and key worker involvement. The manager advised that every 4 weeks a report is compiled by the person’s key worker and this provides an overview of what has happened for the person during the previous month. Risk assessments were completed for all areas of assessed risk and these were seen to be detailed and comprehensive. The management of risk was seen to be proactive in striving for positive outcomes for people whilst ensuring that risks are minimised. Daily care records were noted to be written each day and to contain information detailing how people living at the home spend their day and support staff’s interventions. Records were clear and informative. During both days of the inspection staff, were observed to have a good rapport with people living at Wharf Close. Residents were seen to enjoy the interactions with staff and to respond in a positive way. As a result of people’s complex communication needs, non-verbal cues and interactions were observed. Two residents when asked if they liked living at Wharf Close smiled. From discussions with 2 members of support staff, they were able to demonstrate a good understanding and awareness of people’s care needs and how they like to be supported. The AQAA details that ‘flash cards’ have been purchased so as to encourage better communication with one person who refuses to verbally communicate. Evidence has shown that this has had a positive impact on their communication with staff and others. 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 12 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 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): This is what people staying in this care home experience: 12, 13, 15, 16 and 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assured that their social care needs will be met and that they receive a varied diet that meets their needs. EVIDENCE: People’s social care needs are clearly identified within a plan of care and there is an ‘activity board’ in the office detailing each person’s weekly programme of activities. Records showed that people have access to both formal and informal activities of their choice and according to their individual abilities and needs, both at home and within the local community. The manager is committed to ensuring that people at the home are enabled and supported to attain their goals and to maintain skills and independence wherever possible. 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 14 Where appropriate, education opportunities are actively encouraged, supported and promoted. Activities include arts and craft’s, keep fit, music, cooking, health and beauty, personal shopping, day trips, use of a trampoline, going for walks, cinema, watching television etc. In addition to the above some people attend a local evening club and visit other people in other care homes. Risk assessments are devised in relation to the activities individuals may take part in e.g. use of the trampoline and travelling in the home’s lease vehicle. The AQAA details that since the last key inspection, a piano, swing, camera and photo printer have been purchased for one person. In addition more jigsaw puzzles and other outdoor games have been purchased. It is hoped that within the next 12 months there will be opportunities for people to attend a local gym and to go swimming. Wherever possible people living at the home are encouraged to make decisions and choices about their lives. From discussions with support staff and the manager, people are able to choose what time they get up in the morning, what time they go to bed, whether or not they participate in household chores or social activities etc. We are aware that people living at Wharf Close have a variety of complex needs and are reliant on support staff providing appropriate support and enabling individuals to take risks as part of an independent lifestyle. In addition people are enabled and encouraged to participate in all areas of daily living in the home. For example this includes participation in the weekly food shop, laying the table, clearing the table, putting away their laundry and planning meals. There is an open visiting policy whereby visitors to the home can visit at any reasonable time. People are actively encouraged and supported to maintain close family links and friendships. There is a rolling 4 week menu however we were advised by both the manager and support staff that this is flexible so as to meet individual’s needs and choices. Although a pictorial/written menu has been produced, staff advised us that this has had little impact so as to enable people to make an informed choice. Staff stated that the menu/options available are primarily based on people’s likes, dislikes and personal preferences and a list of personal preferences is recorded for each person. In addition a food diary is maintained for each person so as to determine what has been eaten each day. Residents spoken with indicated through smiling and other non-verbal cues that they were happy with the meals provided. People were observed to have access to drinks and snacks throughout the day. 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their healthcare needs met so as to ensure their health and wellbeing. EVIDENCE: The healthcare needs of each person are clearly recorded and documented within a plan of care. On inspection of those care files case tracked, records showed that each person had a detailed and comprehensive health assessment and action plan. In addition to the contact details of healthcare professionals and services utilised by each person, information was recorded pertaining to a diagnosis of their medical condition, known allergies and current medication regime. Records showed that people living at the home have access to a range of healthcare professionals and services as and when required and these include, GP, attendance at hospital appointments, chiropodist, optician, dentist and consultant psychiatrist. Records are well maintained in relation to healthcare 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 16 appointments and outcomes from these visits. People receive personal and healthcare support using a person centred approach. Where people require assistance with their personal care this was seen to be provided in a respectful and dignified manner by support staff. Storage facilities for medication have been reviewed since the last key inspection and are now seen to be satisfactory. A record is maintained each day of the room temperature where medication is stored. Records showed that these were appropriate and within recommended guidelines. On the first day of inspection both medication cupboards were observed to be not screwed securely to the wall, however when re-inspected on the second day of inspection this had been rectified by the manager. We looked at the medication and medication records for each person in the home and these were seen to be in good order. They provide a clear record and account of medicines in use and demonstrate that people receive the medication prescribed for them. The manager carries out regular weekly checks of the medication records to ensure there are no unexplained errors and this is good practice. PRN (as and when required medication) protocols were in place for each person. Records were seen to be detailed, identifying the specific medication, reason for use, criteria to be met before PRN medication can be given and possible side effects. The protocol for staff to administer PRN medication has been reviewed by the organisation since the last key inspection. This is seen as positive as staff on duty now make the decision as to the administration of PRN medication and then the ‘on-call’ person is advised as to the rationale and circumstances. On inspection of the staff training matrix and random sample of staff training records, records showed that staff who administer medication, have up to date medication training. The manager was advised that regular assessment should be undertaken for staff, who administer medication, so as to ensure their continued competence to administer medication safely. 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home are listened to and protected from harm and abuse, so as to ensure their safety and wellbeing. EVIDENCE: There is a ‘Quick Guide Procedure Summary’ complaints policy in place. In addition a pictorial complaint procedure is displayed. The manager confirmed that as a result of people’s poor communication and cognitive development, they would find it difficult to understand the above procedure, however it is recognised that as a result of staff’s positive relationship with residents, they would be able to identify if people were unhappy. The manager also confirmed that some people have access to an independent advocate and/or family representative to act on their behalf. We were advised that since the last key inspection there has been 1 complaint. The complaints log made reference to informal concerns from the next door neighbour with regards to a resident, throwing items into their garden. Records showed that the above issue has been addressed by the management team of the home and the outcome is that the manager now meets with the neighbour twice a month. There is a safeguarding policy and procedure in place and this makes reference to whistle blowing, referral to the Local Authority and other agencies and 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 18 records to be maintained. A copy of the Southend, Essex and Thurrock Safeguarding Adults Handbook was readily available. Since the last key inspection there has been 1 safeguarding issue. This refers specifically to 1 person being targeted by 2 other people who live at Wharf Close and them being at potential risk of harm. Records showed that as part of a multidisciplinary process, clear management strategies have been implemented to ensure that the person is not at risk. The manager confirmed that strategies implemented have significantly improved the situation at the home and the incidence of incidents has greatly reduced. On inspection of the staff training matrix, records showed that all staff had up to date safeguarding training. 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that is safe and meets their needs. EVIDENCE: A full tour of the premises was undertaken with the manager during the site visit. Since the last key inspection a programme of redecoration and refurbishment has taken place. The home environment is well maintained and decorated to a good standard. The home environment is now light, airy and modern on appearance. The communal lounge/dining room has been newly decorated, new double glazed windows have been installed on the first floor and new vanity units have been purchased and fitted within each person’s room. We tested hot water temperatures from wash hand basins in people’s bedrooms and these were seen to be within recommended guidelines. However 2 people’s taps were 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 20 observed to be stiff when trying to turn the water off and requires reviewing. On inspection of resident’s bedrooms, all were seen to be personalised and individualised, reflecting their personalities and interests. In addition to the above a new boiler and central heating system has been fitted and a new washing machine, tumble drier, dishwasher and cooker have been purchased. The utility room has been refitted and decorated. The garden area is secure and well maintained. People are supported to access the garden as and when they so choose. Appropriate garden table and chairs are available to enable people to enjoy the garden. New gardeners have been employed. 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by competent and qualified staff so as to ensure positive outcomes. EVIDENCE: The manager confirmed that staffing levels at the home remain at 2 members of staff between 07.00 a.m. and 21.30 p.m. and 1 sleeping in person between 21.30 p.m. and 07.30 a.m. each day. From discussions with the manager we were made aware that they receive a limited number of supernumerary shifts per week to undertake supervision for staff, completion of audits and statistics as required by the organisation, attendance at meetings and manage the dayto-day running of the home. This remains inadequate and requires reviewing. On inspection of 4 weeks staff rosters, records showed that the above staffing levels are being maintained so as to ensure people’s safety and wellbeing. Both the manager and staff confirmed that staffing levels are appropriate to meet the current needs of people living at Wharf Close. We were advised that the 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 22 majority of staff have worked at the home and for the organisation for a considerable length of time and have a wealth of knowledge and experience working with people who have a learning disability. Staff spoken with stated that staff morale is “very good” and that they work cohesively as a team. On both days of the site visit, the staff roster accurately reflected staff on duty. The manager confirmed that since the last key inspection to the home, no new staff had been recruited. Recruitment records are located on the home’s computer system and there is an additional set of duplicate records filed and maintained, in case the computerised system cannot be accessed and so as to enable the manager to access information quickly. We looked at a random sample, of 3 staff recruitment files. Records showed that there are good robust recruitment procedures in place and that all records as required by regulation had been sought so as to ensure the protection of individuals. The manager was able to demonstrate that there are clear contingency plans for cover for staff vacancies and staff sickness should these arise. We requested a copy of the staff training matrix and this was provided. Records showed that all staff receive relevant training that focuses on ensuring the staff team are able to meet the needs of people living at Wharf Close. The manager confirmed that the majority of training is renewed and updated every 3 years. Consideration by the organisation to review the time-span between training undertaken should be reviewed, as legislation in some areas may change on a regular basis and staff may find that some aspects of their training becomes out of date and/or obsolete. The manager confirmed that she is currently awaiting dates for staff to undertake training relating to the Mental Capacity Act. The manager has devised and implemented a ‘personal development plan’ for each staff member which identifies their individual goals for achievement and how this links to the organisations ‘Operational Plan’. The AQAA details that all permanent staff working at the home have attained NVQ Level 3. A random sample of 3 people’s supervision records were examined. Records showed that staff are receiving regular formal supervision in line with National Minimum Standards recommendations. 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People at the home benefit from a well run home that meets their needs. EVIDENCE: The manager has worked in the social care sector for over 18 years, when she started working as a care assistant with Thameside, whose services were then taken over by Family Mosaic, and has stayed with them throughout. The manager was appointed as the manager of Wharf Close in November 2007. An application to be formally registered with us was submitted and the manager attended a ‘Fit Person Interview’ on 11th May 2009, whereby she demonstrated “excellent skills to enable her to successfully manage the service applied for”. Following this interview it was deemed appropriate for the manager to be formally registered with the Care Quality Commission. The manager 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 24 successfully completed her Registered Managers Award in June 2008 and has attained NVQ Level 4 in Care. Records also show that the managers training in core subject areas was up to date and she has recently attended Mental Capacity Act and Deprivation of Liberty training. The manager was able throughout the 2 days of inspection to demonstrate a good awareness and understanding of National Minimum Standards, regulatory requirements, current residents care needs, areas of risk and was clear about her role and responsibilities. The manager understands the principles of person centred care and the value of ensuring that people at the home are supported to develop and maintain skills and to be as independent as possible but recognising their limitations and complex care needs. At the previous key inspection to the home 4 requirements and 2 recommendations were highlighted. At this inspection there was evidence to show that all have been achieved. The manager feels that staff morale is “very good” and staff are fully aware of their roles and responsibilities, both in line with regulatory requirements and the organisations own corporate policies and procedures. Staff spoken with were very complimentary regarding the management of the home and expressed no concerns regarding the manager’s ability to the running of the home in all areas. Comments included “the manager is lovely, the home is managed well” and “the manager is good”. All sections of the AQAA were completed and the document returned to us when requested. The AQAA provides details about any changes they’ve made since the last key inspection and where they still need to make improvements. We looked at the report of the results for the 2008-2009 ‘satisfaction survey’ for people who live at the home and their representatives, whether a family member or an independent advocate. Records showed that people are happy with the care and support provided by staff. The AQAA details that as part of the satisfaction surveys additional initiatives to improve the service further have been recommended. These include relatives meetings to be held more frequently, more use of the Mencap Society day trips that are organised, the introduction of a ‘friendship circle’ so that people can meet up with old friends who live in other homes and to organise themed nights. The manager confirmed that the results from staff surveys are not yet known. A health and safety policy was observed within the home. A random sample of safety and maintenance certificates showed that these had been serviced, and remain in date until their next examination. Health and safety checks are carried out on a weekly basis by staff and the manager completes a monthly audit. A fire plan and fire risk assessment for the home was readily available. Records for monthly fire checks and fire drills evidence these are conducted regularly. 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 25 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 3 23 3 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 3 3 3 X 3 X 3 X X 3 X Version 5.3 Page 26 1 Wharf Close DS0000018081.V377563.R01.S.doc Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 YA24 YA32 Good Practice Recommendations Wash hand basin taps in people’s rooms should be easier to turn off as currently they are stiff. Consideration should be made by the organisation to enable the manager to have additional supernumerary shifts. 1 Wharf Close DS0000018081.V377563.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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