Care Home: 26 Stockdove Way

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CARE HOME ADULTS 18-65 26 Stockdove Way 26 Stockdove Way Perivale Middlesex UB6 8TJ Lead Inspector Jane Collisson Unannounced Inspection 9th February 2009 10:00 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 26 Stockdove Way Address 26 Stockdove Way Perivale Middlesex UB6 8TJ 0208 810 6699 0208 810 8104 hm26stockdove@ealing.org.uk www.supportforliving.org.uk Support for Living 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) Care Home 7 Category(ies) of Learning disability (7) registration, with number of places 26 Stockdove Way DS0000027730.V374118.R01.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 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: 7 2nd April 2008 Date of last inspection Brief Description of the Service: 26 Stockdove Way is a care home providing personal care and accommodation for seven people with a learning disability. The home is situated on a housing estate close to the A40 and public transport to Ealing Town Centre. The Registered Provider for the home is Support for Living (formerly Ealing Consortium) and the house is owned and maintained by Notting Hill Housing Trust. It is purpose built and was opened in 1995. The home adjoins 246 Haymill Close, which is also for seven people with a learning disability. Between the homes, which are separated by entry-coded doors, is a shared staff sleeping-in room and bathroom. In addition to the office within the Stockdove Way home, there is an office shared with the Haymill Close staff. There are seven single bedrooms situated over two floors, and the home is wheelchair accessible with a lift between the floors. There are four bath and shower rooms, separate toilet, lounge, dining room and kitchen. There is access from the lounge to the large, well-maintained garden at the rear of the property. There is parking to the front of the house. The staff team consists of a Manager, three Deputy Managers, and a team of Support Workers. There is one waking night staff for Stockdove Way and an additional waking night shared with Haymill Close. 26 Stockdove Way DS0000027730.V374118.R01.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 2 star. This means the people who use this service experience good quality outcomes. This unannounced inspection commenced on the 9th February 2009 from 10.10am to 4.30pm. The Manager was on duty with four members of staff. During the day, all of the residents were in the home. Four people attended sessions at the neighbouring day centre, also managed by Support for Living. One resident attended the hospital appointment and another resident went out shopping with a staff member. Two additional short visits were made on 10th and 13th February to look at further records. The inspection took a total of nine hours. We found, on the second visit, that there were errors in the medication stock records and the Manager undertook to correct these by the 13th February. He was in the process of carrying out an audit when we visited on that day. The Manager had recently undertaken the Commission for Social Care Inspection interview for registration and was awaiting the certificate. During the inspection we looked at a variety of records, including care planning files, staff files, training records, complaints, finances, maintenance and medication. We observed the residents having lunch, which is prepared by the cook. We had sent surveys to the residents and staff prior the inspection and received four residents and five from staff. The majority of the residents are non-verbal and had support in filling in the surveys. We spoke to one person who was visiting a resident on the last day of the inspection. We toured the home on the first visit with the Manager. New furniture has been purchased for the lounge since the last inspection and new carpets are to be fitted in communal areas. One of the bathrooms has been refurbished with a new assisted bath/shower. All seven residents are over 60 years of age. Five of the residents use wheelchairs to go out and some use them in the home. Those who have good mobility, or can mobilise with a wheelchair, use all parts of the home. During the course of the inspection, we saw one person relaxing in her room. Another person was watching television for most of the time and the other people were at the day centre or out with staff. People can access the day centre for a maximum of nine hours a week, or receive four and a half hours in of individual support. Sessions include drama and aromatherapy. The home has the use of transport for outings, including a car owned by one of the residents. There are no specific cultural or religious needs to be met. We found that the majority of the requirements made in April 2008 had been met. 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The medication audits, which had been put in place, were not sufficient to ensure that an audit trail was in place. Better monitoring by the management staff is needed to ensure that all medication can be fully accounted for. Where the Housing Association is not responding to requests to repairs when potentially hazardous issues are reported, the Registered Providers must ensure that maintenance issues are carried out within a reasonable timeframe. A system must be in place to ensure that reminders to the Landlords are recorded so that action can be seen to be taken. The Manager must ensure that staff receive their updated training, particularly for safeguarding adults and epilepsy, when it is due. The level of National Vocational Qualifications training remains low. The Registered Providers must ensure that the staff have the opportunity to undertake National Vocational Qualification training to develop their skills, so that the National Minimum Standard of having 50 of the staff team trained can be achieved. An Action Plan is required to show how this will be achieved. The reports for the monthly visits by the Registered Providers to the home have been irregular and need to be completed on a monthly basis to support quality assurance. To ensure that all of the precautions are in place for fire safety, the home must ensure that there is a fully completed risk assessment for which is in 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 7 accordance with the Regulatory Reform [Fire Safety] Order 2005). This is a repeated requirement. 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. 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available for people to make a decision about moving to the home. The facilities in the home suit the needs of people with poor mobility. Assessment procedures are in place. EVIDENCE: The Statement of Purpose and Service Users Guide have been updated to include details of the Manager, who commenced at the home in March 2008. The Service Users Guide has some visual content but would not be accessible to most of the residents of the home. We could not examine the assessment procedures fully as there have been no vacancies in the home and no new residents since 2007. It has been agreed that the home is not suitable for one of the residents and a new placement is being sought. There are assessment processes in place should a vacancy occur and these were updated in October 2008. The home is purpose built and has the facilities, such as wide corridors, for wheelchair users. A lift was installed two years ago to make the bedrooms on the first floor more accessible and allow people to remain in the home. The bathrooms have showers and an assisted bath and there are overhead hoists 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 10 in some of the rooms. There are day service facilities very close for the residents to enjoy. 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although people cannot participate fully in their own care planning, the staff show a good awareness of their preferences which support their lifestyle and quality of life. Individuals are encouraged to make their own decisions and choices within their capabilities. Communication needs are known and visual prompts are in place. Risk assessments have been carried out but would benefit from reviewing in full. EVIDENCE: There were a number of requirements, at the last inspection, for improvements to be made to the care plans to ensure that they were relevant and up-to-date. The Manager said that a new Person Centred Planning (PCP) system is being introduced. Two samples of PCP reviews were seen when three files were examined in detail. There have been reviews for all of the people in the home and information appeared to be up-to-date. However, there is a large amount of information being held which would benefit from being streamlined and the older information archived so that the files are easier to use, particularly when 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 12 agency or new staff are in post. Each resident has a key worker who supports them specifically and they produce a useful monthly report, which includes activities, medical appointments and other notable events. This includes the progress of the items agreed at reviews. As the PCP system is new, it could not yet be seen how the new process was impacting on the care plans and records as not all of the monthly reports were up-to-date. However, it was seen that reviews were taking place, involving the families and advocates where ever possible. One had been rearranged recently to ensure that the person’s representatives could attend. The residents’ health needs are being met by community services and it was seen in the files we examined that records are in place for general practitioner and other health visits. These included those for chiropody, dental and optical visits. We saw that appropriate specialist help had been sought for one person to support them through a difficult period. While people are not able to be independent outside of the home, we saw that people make their own decisions about where they wish to be in the home and were able to make these decisions known to the staff. There were a large number of risk assessments in place for any possible health and safety issues which might arise for each person, and these had dates of review. However, the original risk assessments were often compiled some years ago and it is recommended that all of the risk assessments are renewed, preferably into a common format which is easy to follow, particularly for agency staff and any new staff who may be appointed. We found that the kitchen remains locked for safety reasons but that people do have access with staff support. 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 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. Residents are involved in daytime activities of their own choice and according to their individual interests, needs and capabilities. People have the opportunity for holidays. Families and advocates are able to visit as they wish. EVIDENCE: We saw that people are encouraged to retain their independent living skills. Although most people are limited in the way in which they can carry out everyday tasks, we observed people undertaking small tasks, such as clearing crockery after lunch, rather than staff doing this for them. Because the majority of the people living in the home have limited or no verbal communication, we were not able to discuss their wishes with regards to outings. However, people are able to make their wishes known and we saw an example of one person wishing to go out to the shopping centre, which she chooses to do on a regular basis. We found from the records, and through 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 14 talking to staff, that people have the opportunity for day services, both in groups and on an individual basis, and for outings. Visits to a local pub and the cinema were among the outings seen to be recorded. Four of the seven residents have families or friends who are able to act as advocates. One was in the home during the inspection and visits on a regular basis. All of the people had the opportunity to go on holiday in 2008 and all but one chose to do so. People generally take short breaks of four days, in small groups. The home employs a cook, for five hours a day on weekdays, who prepares a cooked lunch for the people living in the home and the evening meal for the staff to complete. She has worked in the home for many years and knows well the likes and dislikes of the residents. The meal we observed was freshly cooked pasta for lunch and fish and vegetables for the evening meal. The cook had prepared pureed fresh fruit as well as a small sweet dessert to encourage healthy eating. Although there is a set menu, where a different meal is preferred, the cook is able to accommodate this. We observed this on the first day of the inspection. There is a separate dining room and large table. As some of the residents have to be supported with meals, it can be quite crowded. However, staff said that the residents generally prefer to eat together. Where anyone wishes to eat separately or in another room, which does occur, this can be accommodated. We saw that equipment, such as special plates and cutlery, have been purchased to assist the residents. There were no special dietary needs being met apart from the management of one person’s high cholesterol None of the residents require any special cultural or religious requirements in regard to food. 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 This outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive the support they require through the community services. Staff support people in accordance with their needs. Medication audits were insufficient to ensure that people are protected by good medication administration. EVIDENCE: People require support with their personal care and a separate personal care assessment is carried out for each person. There are sufficient bathrooms for people to have a choice of equipment which suits them and to retain privacy. One person requires the support of two staff and same gender care is provided. The majority of the residents require support with their mobility outside of the home. Some require wheelchairs to get around the home. The lift has enabled residents easy access to the first floor bedrooms and helped to retain independence. One person is required to be transferred by hoist and there are overhead hoists to accommodate this. The emotional needs of one of the 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 16 residents have been met with professional involvement and it has been discussed that a new placement might be better for the person. We noted, from the records provided, that not all of the staff have recent training in epilepsy and rectal diazepam administration. As a number of the residents have epilepsy, all staff should be trained in this. A pharmacy visit had been undertaken in September 08 and a number of recommendations were made. The Manager said that these had been carried out. We found that the amount of PRN (as and when) medication is checked on a daily basis. However, we found a number of errors on the second visit in the medication auditing procedures. While a stock check had recently taken place of the medication, this had not been checked against the amount of medication delivered and administered. Therefore there was no audit trail. We checked two samples initially and neither agreed with the amount left in stock. One had a large excess of medication which needed to be returned to the pharmacy. We saw that the pharmacy had been delivering twice the amount required for the month for one medication but the staff had not corrected this with the general practitioner. The Manager was asked to check all of the medication and ensure that there was an audit trail for all of it by the return visit on Friday 13th February. When we returned for the last visit, the Manager was in the process of undertaking a medication audit as the new Medication Administration Record sheets and new stock had just commenced for the following twenty eight days. He was sending the excess medication back to the pharmacy. Two errors had been identified in the amounts that the pharmacy was sending to the home. He had also prepared a list for each person of all of the medication prescribed so this can be checked when new stock arrives. There were fourteen medication errors identified since the last inspection and a record is kept of these. Errors included medication not given and missed signatures. The Manager said that people are spoken to in supervision about these and retrained if necessary. Records of medication competency training were seen in the staff files examined. The Manager must ensure that he and the senior staff are involved in regular medication checks which ensure there is a clear audit trail of medication received, carried forward, administered and disposed of. Where staff are delegated to do this task, it must be ascertained that they understand the process of an audit trail. 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints procedures are in place but the residents would require support to make their concerns known. Safeguarding adults’ issues have been raised and investigated. Financial procedures now help to safeguard peoples’ money. EVIDENCE: The service has a visual complaints procedure but the majority of the residents would not be able to use this to make a complaint on their own behalf. Two of the residents have family members who visit and two more have advocates to speak for them. There have been no complaints recorded since the last inspection or made through the Commission for Social Care Inspection. There have been three issues raised through the safeguarding adults’ procedures since the last inspection. These have been reported through the Community Team for People with Learning Disabilities and investigated. The Commission for Social Care Inspection were not invited to the initial meetings and the Manager and staff need to ensure that they are informed promptly. One of the safeguarding adults’ issues concerned missing money. The investigation was inconclusive. Since the incident, the procedures for managing residents’ money have been improved and we saw that checks are made at each handover and the Deputy Managers also make regular checks. A monthly transactions sheet, together with the bank statement, goes to the organisation’s head office and the Manager said that audits are also carried out 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 18 by the head office staff. There are limits to the amount of money that can be spent without permission of senior staff. We looked at two of the records for the residents’ finances. Each person has their own record book and six people have bank accounts. One person has their money managed through the Court of Protection. Though the majority of staff have had training for safeguarding adults in the last three years, four of the thirteen staff require the updated training. In view of the safeguarding adults’ issues in the home, this needs to be carried out at the earliest possible opportunity. 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to meet the specific needs of the people who live there. Specialist aids and equipment are provided to meet their needs. The bathrooms and toilets are fitted with appropriate aids and adaptations to meet the needs of the people who use the service, and are in sufficient numbers and of good quality. The home is clean and tidy and smells fresh. EVIDENCE: We found that the communal areas provide a pleasant environment for the people living in the home. New settees and chairs have been provided since the last inspection and new carpets are to be laid in the communal areas shortly. The residents have the use of a large lounge and a separate dining area. The kitchen is kept locked for safety but people were seen to be in the kitchen with staff to get drinks. There is access from the lounge to a good sized, well maintained garden 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 20 Bedrooms have the individual equipment to suit the person, such as overhead hoists. Since the last inspection a new assisted bath/shower has been installed in one of the bathrooms on the first floor. We found on the first day of the inspection that the roof in the other first floor bathroom was leaking, close to the electric light. This had been reported to the Housing Association in December but had not been repaired. On the second day of the inspection, the Housing Association staff had arrived to carry out this work. Staff need to ensure that the landlords are kept informed of any potentially harmful health and safety issues and a record kept of all contact with them. Where the repairs are not being carried out, the Registered Providers need to take appropriate action. A domestic staff member is employed for cleaning the home and it was found to be clean and orderly. Since the last inspection, there are now hand drying facilities in the toilets. 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There appear to be sufficient staff to meet the needs of the residents but attention could be given to using the staffing more creatively. Staff receive the relevant basic training which is usually updated when required. The National Vocational Qualifications targets have not been met. The information on staff records could be improved to show that all of the National Minimum Standards are met. Staff meetings and supervision take place regularly. EVIDENCE: The current staffing for the home is four staff on the early shift, and three on the late shift. There is one waking night staff and, at the present time, an additional waking night staff is shared with Haymill Close, the neighbouring home, in place of a sleeping in staff. There are three Deputy Managers and there is usually one Manager on each shift, except at weekends. The Manager said that, where there is no Deputy on duty in Stockdove Way, there will be a Deputy at the Haymill Close to support the staff if necessary. Staff commented that they did not feel there were always sufficient staff to meet the individual needs of the people using the service. We noted that there 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 22 could be some difficulty in taking more than one person out in the late afternoon or evening, and this would be more difficult if the person required two staff to escort them. The Manager said that additional staff can be put on the rota if there are planned activities, but this does preclude the more spontaneous outings, particularly in the summer months. As there were four staff on duty when some people are at the day centre, it is possible that some rearrangement of the rotas could be considered and this is recommended to the Manager. There were four staff vacancies and agency staff are still being used. The Manager said that recruitment is in progress to fill the vacancies. It was a requirement at the last inspection that staff had the required training courses which were up-to-date. The Manager provided a list of the staff and the basic training courses they have undertaken. The majority have undertaken the first aid, food hygiene, fire safety, health and safety and manual handling. Although some staff have been booked on courses in the near future, there were some gaps in safeguarding adults and epilepsy training which need to be completed. We looked at a sample of three staff records in regard to the training they had undertaken. One newer member of staff had undertaken all of the basic courses including first aid, health and safety, manual handling, epilepsy, equal opportunities, life support and physical intervention. Staff were complimentary about the training that Support for Living provides. The staff were not seen to have an individual training and development plan to record the courses undertaken and how they can develop their skills. The Manager said that this is discussed in their appraisals. The number of staff with National Vocational Qualifications training has not met the target of having 50 of the staff trained. Out of a permanent staff team of thirteen, two have a National Vocational Qualification at Level 2. One is going on to take Level 3. Two have qualification at Level 3, and two are currently undertaking this. The Manager said that there is now a training programme for National Vocational Qualification. The Registered Providers must ensure that the staff have the opportunity to undertake this training to develop their skills and the National Minimum Standard of having 50 of the staff team trained should be achieved. A staff meeting took place during the first day of the inspection and the Manager said that they try to hold these weekly. A staff member from the neighbouring home sat with the residents. The meeting was nearly 1.5 hours and the Manager needs to ensure residents are not regularly left without the opportunity for activities for this long, on a regular basis. We saw samples of the supervision sessions which are held and the National Minimum Standards of at least six a year is met. 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 23 We saw samples of three permanent staff records. The home keeps only basic information about the staff. This showed that Criminal Records Bureau disclosures had been obtained, two references had been taken up, and a full employment history had been obtained. However, there was no information on qualifications or experience, contracted hours or a job description. We also looked at eight records of the agency staff who were on the current rota. Not all of their details were immediately available but the Manager found them on the computer. The information we saw included details of Criminal Records Bureau disclosures and training. Although most of it appeared to be current, there was a small amount of training which was recorded as out of date. Information on all of the staff working in the home must be available for inspection and it needs to be checked regularly to ensure it is current. Staff were generally positive about working in the home, the support they received. Several of the staff have worked there for some years and provide continuity for the residents. 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 24 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 good. This judgement has been made using available evidence including a visit to this service. The management and running of the home has improved and the manager has the experience to improve them further. Quality assurance systems are in place, but the monthly checks, by the Registered Providers, are not always regular. Record keeping is in need of improvement to ensure that the relevant information can be easily accessed. EVIDENCE: The Manager has been in post since March 2008 and had recently completed the Commission for Social Care Inspection registration process. He has the National Vocational Qualifications Level 3 and said he will be undertaking the Leadership and Management for Care (NVQ Level 4) qualification. The home has a pleasant atmosphere and several of the staff team have been in post for some years. However, a number of agency staff are used regularly each week and the home would benefit from a permanent staff team. 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 25 We saw that Regulation 26 visits have not been completed regularly and only one had taken place in the last four months. As there are outstanding actions, with timescales, it is important that there is sufficient monitoring, by the Registered Provider’s senior staff, to ensure that all of the outstanding issues and requirements are completed. The Annual Quality Assurance Assessment had not yet been requested for 2009 so was not available. The Registered Providers have quality assurance systems in place and we saw monitoring for the period October 2008 to December 2008. This had information about the reviews of the residents and any outcomes, staffing levels and vacancies, maintenance items, complaints and feedback from relatives and advocates. The residents had also recently been supported to complete surveys but these had not yet been analysed. We saw that Support for Living have had new policies and procedures since the last inspection. When we looked at a sample of the maintenance records, not all of them appeared to be up-to-date. However, on checking with the Manager, he provided us with the more recent evidence of the servicing checks. These included the Legionella testing in August 2008 and the lift service in January 2009. The fire records were seen and the last drill took place in January 2009. Fire alarms are tested weekly, although some gaps were seen. The current fire risk assessment is dated 2007 and does not appear to have been compiled in conjunction with the latest legislation. The Manager said that a new format had been sent to the home and a staff member had been on training for this. This was an outstanding requirement in April 2008 and must be completed with the timescale given. Although some improvement have been made to the record keeping, there was a great deal of documentation which could be archived. There was information on maintenance, for instance, in several files and the simplification of the files would make it easier for both inspection and for the daily use by the staff. It was observed that they also found difficulty in locating files and information. 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 26 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 3 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 2 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 2 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 2 X 3 3 2 3 X 2 X 26 Stockdove Way DS0000027730.V374118.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES 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 YA20 Regulation Requirement Timescale for action 31/03/09 2 YA24 3 YA35 4 YA35 13 The Manager must ensure that (2)17(1)(a) he and the senior staff are Sch.3 (i) involved in regular medication checks which ensure there is a clear audit trail of medication received, carried forward, administered and disposed of. Where staff are delegated to do these tasks, it must be ascertained that they understand the process of an audit trail. 23 (2) (c) The Registered Providers must 31/03/09 ensure that maintenance issues are carried out within a reasonable timeframe. A system must be in place to ensure that reminders to the Landlords need are recorded so that action can be seen to be taken when potentially hazardous issues are identified. 18 (1)(c)(i) The Manager must ensure that 31/03/09 all staff have the regular training updates in safeguarding adults and epilepsy within the required timeframes. 18 (1) (c) The Registered Providers must 30/04/09 (i) ensure that the staff have the opportunity to undertake DS0000027730.V374118.R01.S.doc Version 5.2 26 Stockdove Way Page 28 5 YA39 26 6 YA42 23 (4A) National Vocational Qualification training to develop their skills, so that the National Minimum Standard of having 50 of the staff team trained should be achieved. An Action Plan is required to show how this will be achieved. The Registered Providers must ensure that the unannounced monthly visits required under this Regulation are carried out monthly. The Registered Providers must ensure that the fire risk assessment is fully completed in accordance with the fire legislation (Regulatory Reform [Fire Safety] Order 2005), which came into force in October 2006. and in accordance with its own policies and procedures. (Previous timescale of 31/05/08 not met). 31/03/09 31/03/09 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 YA9 Good Practice Recommendations That the risk assessments for individual residents are reassessed, using a common format. This to ensure they are all current and it will aid the staff, particularly agency and new staff, to easier understand the minimisation of risks and any guidance that is in place. That changes to the rota and a different deployment of the staff are considered to ensure that there are sufficient on duty at times when the residents may like to go out spontaneously. That more attention is paid to better record keeping and administration to ensure that archiving takes place, files are streamlined and made easier to access. DS0000027730.V374118.R01.S.doc Version 5.2 Page 29 2 YA33 3 YA41 26 Stockdove Way Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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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