Care Home: Alsop House

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What the care home does well The service continues to review its systems to ensure the needs of people who wish to spend respite time at Alsop House are fully assessed and detailed care plans are produced and reviewed before each stay. People are encourage and supported to make their own decisions and to take controlled risks. Risk assessment procedures followed by the service promote and support people to live independent lifestyles. The service encourages and supports people to express their views. There well being and safety is protected by the service`s policies, procedures and practice. The service is run by a competent and experienced manager and good systems are in place to ensure people are supported by trained and competent staff.Alsop HouseDS0000041325.V377634.R01.S.docVersion 5.3 What has improved since the last inspection? The service has addressed both requirements made at the last inspection. Some re-decoration and refurbishment has taken place. For example the lounge has been re-decorated and the carpet replaced. The kitchen has been upgraded and breakfast bar fitted. The access to the rear of the building has been made more secure. People who use the service are more actively involved in planning and reviewing the individual support they receive from staff and regular meetings are held to consult them on the day-to-day running of the service. Formal shift hand over meetings continue to take place and a staff book has been introduced to improve communication between the team. This provides staff with a quick reference to information they need to know and issues they need to read in full on people`s daily notes or care plans. What the care home could do better: The service needs to ensure a comprehensive assurance system is in operation that enables people who use the service, their relatives and other interested parties to be fully confident their views underpin the service`s own monitoring and review of its practice and make available an annual development plan. A system for recording the handing over of responsibility for people`s medication should be introduced. This will ensure the person dealing with their medication can be easily identified for monitoring and auditing purposes. The competency checks previously carried out for medication practices should be re-introduced to ensure procedures are being appropriately followed. Staff should receive a minimum of six planned supervision sessions a year. The content of these sessions should be reviewed. They should look in depth at the individual`s practice and how the aims and objectives of the service of the service are being met. Periodic training should be planned for staff to update their knowledge on protection issues. The manager should also be supported to plan for her own training and development.Alsop HouseDS0000041325.V377634.R01.S.docVersion 5.3 Key inspection report CARE HOME ADULTS 18-65 Alsop House 2 Rowland Vernon Way Tipton West Midlands DY4 0RF Lead Inspector Linda Elsaleh Key Unannounced Inspection 14th September 2009 11:00 Alsop House DS0000041325.V377634.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. Alsop House DS0000041325.V377634.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 Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Alsop House Address 2 Rowland Vernon Way Tipton West Midlands DY4 0RF 0121 557 2660 0121 557 2660 alsop@sandwellcct.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Sandwell Community Caring Trust Ms Susan Coleman Care Home 6 Category(ies) of Physical disability (6) registration, with number of places Alsop House DS0000041325.V377634.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. Physical disability (PD) 6 The maximum number of service users who can be accommodated is: 6 23rd September 2008 Date of last inspection Brief Description of the Service: Alsop House is a purpose built bungalow located in a residential area of Tipton. The Home provides short stay respite care for up to six adults who have physical disabilities. There is a maximum stay of three months. This is a unique service; the only provision of its kind in the borough of Sandwell. There is a small car parking area at the front of the property. The garden is situated to the rear of the property. There is level access to the front and rear of the building. The Home was registered in February 2003. There are six single bedrooms all with en-suite shower facilities. Two bedrooms have overhead tracking hoists. There is also a bathroom with an overhead hoist. There is a lounge, and open plan kitchen and dining area. The Home has a conservatory that is also used as a smoking room. Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 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 that the people who use this service continue to experience good quality outcomes. We looked at the information we received about the service since it was last inspection. The manager was asked to complete an annual quality assurance assessment (AQAA) to tell us about what has happened during the last year and bring us up to date with relevant facts and figures. This unannounced inspection was carried out by one inspector on 14th September 2009. We spoke to the staff and the people who use the service. We looked at the files of people who were staying at Alsop House, the files of three staff and a random selection of other records kept by the service. This was done as part of our process to assess the outcomes for the people who use this service. The atmosphere in the home was relaxed and friendly. People appeared healthy and well looked after and told us they enjoyed coming to stay at Alsop House and the staff were very good. The premises were clean, tidy and suitably furnished. What the service does well: The service continues to review its systems to ensure the needs of people who wish to spend respite time at Alsop House are fully assessed and detailed care plans are produced and reviewed before each stay. People are encourage and supported to make their own decisions and to take controlled risks. Risk assessment procedures followed by the service promote and support people to live independent lifestyles. The service encourages and supports people to express their views. There well being and safety is protected by the service’s policies, procedures and practice. The service is run by a competent and experienced manager and good systems are in place to ensure people are supported by trained and competent staff. Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 Page 6 What has improved since the last inspection? What they could do better: The service needs to ensure a comprehensive assurance system is in operation that enables people who use the service, their relatives and other interested parties to be fully confident their views underpin the service’s own monitoring and review of its practice and make available an annual development plan. A system for recording the handing over of responsibility for people’s medication should be introduced. This will ensure the person dealing with their medication can be easily identified for monitoring and auditing purposes. The competency checks previously carried out for medication practices should be re-introduced to ensure procedures are being appropriately followed. Staff should receive a minimum of six planned supervision sessions a year. The content of these sessions should be reviewed. They should look in depth at the individual’s practice and how the aims and objectives of the service of the service are being met. Periodic training should be planned for staff to update their knowledge on protection issues. The manager should also be supported to plan for her own training and development. Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 Page 7 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. Alsop House DS0000041325.V377634.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 Alsop House DS0000041325.V377634.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): 1&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. People have sufficient information to enable them to make an informed decision about whether they would like to have their respite stay at Alsop House. Their needs and aspirations are fully assessed to ensure these needs can be met before a placement is agreed. EVIDENCE: This service provides respite care for people who have a physically disability. A Statement of Purpose and Service User Guide is available to inform them about what the service has to offer and how their individual needs can be met during their stay. People we spoke to as part of our inspection process told us they felt they were given good information about the service and they able to speak to staff if they have any queries. We looked in detail at the files of two people who receive a service. There was written confirmation to show they had been provided with a copy of the Statement of Purpose and Service User Guide. There were copies of assessments and reports from social and health care agencies, which the Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 Page 10 service had requested as part of its referral process, and the service’s own assessments. One member of staff told us she had visited a person who had shown an interest in receiving a respite service at Alsop House with the manager to carry out an initial assessment. Other staff we spoke to said people are invited to look at the facilities and meet with members of staff. This enables the service to discuss with the individual how their needs and any personal preferences are to be met during their stay. Most people have regular stays at Alsop House throughout the year. Therefore, the service has systems in place to check for any changes in their needs that may have occurred since their last visit. This is to ensure the service can continue to meet their needs. Information provided to us by the manager prior to our visit tells us the service has made improvements in how it assesses people’s needs and involves them more in planning for their own care. This was evident in the two people’s files we looked at. The manager told us they had not carried out any recent assessments. However, we were shown a copy of the revised assessment documents and were informed the service plans to update the Statement of Purpose to reflect these changes. Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 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. Peoples needs and personal goals are reflected in their care plans. They are encouraged to make their own decisions and supported to take risks as part of an independent lifestyle. EVIDENCE: Care plans are produced based on the assessment information and discussions with people who wish to use the service. The manager tells us the way in which care plans are produced has been revised following the changes to the assessment procedures and consultation with people who use this service. The care plans we looked at show all aspects of people’s personal, social and health care needs and, where applicable, risk assessments are undertaken. We spoke to staff about the changes and they told us some plans and risk assessments Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 Page 12 have yet to be produced in the new format, but they are working with people to do this when planning for their next stay at Alsop House. People we spoke to told us about the support they need and how this is provided. One person told us s/he is independent and manages their own medication and finances. However, they do require support from staff when out in the community because of their lack of confidence. Another person told us staff assists them with their personal care and manages their medication. Both people told us they are consulted about how they wish to be supported on a regular basis. Relatives we spoke to told us people always receive the care they need and are consulted about how this should be provided. People are encouraged to continue to make their own decisions as they would do when they are in their own homes. However, the staff team are available to provide advice and assistance. The records show people are also supported to access an independent advocacy service. One person is being supported to consult with the local authority about being allocated suitably living accommodation in the community. The service holds weekly meetings with people who are staying with them to discuss day-to-day issues. The records show their views and comments are acted upon to provide the service people want. For example, a new floor has been fitted in the bathroom to enable people, who are able, to safely manage their own personal care. Most of the people we spoke to said they enjoy the weekly meetings and are pleased with the service’s response to their comments and suggestions. Alsop House DS0000041325.V377634.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, & 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 encouraged and supported to participate in activities and to maintain links in the local community. Their rights are respected and they are assisted to follow their own daily routines. People are able to choose their own meals and are provided with a pleasant environment to enjoy mealtimes. EVIDENCE: People are able to continue to follow their usual daily routines such as attending clubs. They arrange their own transport or receive support from staff to do so. The service also has its own vehicle which means people with large wheelchairs have access to suitable transport. People tell us this enables them to go shopping, take trips to the local pubs and enjoy meals out. Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 Page 14 We observed staff supporting people to follow their own routines. For example one person had chosen to have a ‘lie in’ and was assisted with their personal care at a time of their choosing. People we spoke to told us they able to choose how they spend their time and staff respect their right to privacy. During this visit two people chose to spend most of their time in the kitchen playing cards, while another spent time in the lounge watching television. Good interaction was seen between people and staff. A member of staff joined the people playing cards, another spent time chatting to the person in the lounge. Throughout the visit we saw staff meeting people’s needs on request for example, providing drinks and assisting them to go to their bedroom or the toilet. People did not receive any visitors during our visit. However, they told us they are able to arrange for visitors at any time and can receive them in the privacy of their bedroom. Relatives we spoke to told us they are always made to feel welcome and are able to speak with their relative on the telephone at any time. One person told us the service is very good at keeping them informed about what is happening. Foe example, they were contacted by staff when her husband had a minor accident. The service has a flexible approach to providing meals and therefore does not have planned menus. Individuals are able to choose the meals they want on a daily basis and records are kept of meals taken for monitoring purposes. Fluid intake charts are also kept, when required. This was being completed for one person during our visit. There is also a flexible approach to mealtimes and one person was seen having a late breakfast. People who have difficulty eating are supported in a sensitive manner. Another person told us the service meets all their cultural dietary needs. There is a spacious and well equipped kitchen and dining room and people, who are able, are encouraged to prepare their own drinks and meals. The staff team are trained in basic food hygiene and 50 have received training malnutrition care. Alsop House DS0000041325.V377634.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 & 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 receive support in the way they prefer and require so that their physical and emotional needs are met. They are supported to retain and administer their own medication where appropriate and protected by the service’s procedures and practices in dealing with medicines. EVIDENCE: People are support by staff with personal care in accordance with their care plans and wishes. One person told us they need a lot of help and this is provided in the way they like and at a time of their choosing. The daily records show various times when this person has been supported to get up, for example on the day of our visit the person chose not to get up until 10:30. The service has replaced the floor covering in the bathroom to reduce the risk of slips and falls for people who are able to bathe independently. Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 Page 16 The current staff team is all female. We asked how the service would meet requests from men who would like to be supported with their personal care by a male member of staff. The manager informed us there are male members of staff on the company’s relief staff team. These staff members are familiar with the service and would be allocated to work throughout the person’s stay. Everyone who stays at Alsop House has access to the health care they need. They are supported to attend appointments with health care professionals such as the dentist and chiropodist. Records kept on people’s files show arrangements are made for visits to/from their doctor when they are ill. Each person has a medication plan which details how this is to be managed. Two of the three people receiving a service at the time of our visit have their medication managed on their behalf by staff. They told us they are happy with this arrangement and always receive their medication on time. The person who looks after their own medication is provided with a lockable facility in their room and a key so s/he can keep her/his medication safe. The person has signed a form to say they will be managing their own medication and this is kept on their file. Information provided to us by the service show its medication procedures were last reviewed in January 2009. The procedures were accessible for staff to refer to at any time. It is advisable for the date of review to be included on procedures and a system introduced to ensure the staff team are made aware of any changes. There are suitable facilities for storing medication managed by the service. We looked at the medication administration record (MAR) sheets for the two people whose medication is being managed for them. These records were complete and no gaps in recording were seen. The service also has a system for carrying out periodic checks on medication with the people who selfmedicate. Medication is managed by staff trained to do so. Their names and sample of their signature and initials are kept in the medication folder to assist with the monitoring and auditing of records. Staff informed us of the process for handing over the medication key at shift changes. There is no system for recording this. The manager is advised to introduce a recording system similar to the one used for passing responsibility from one staff to another for money being held by them for people who are using this service. During the last twelve months the service has informed us of two incidents concerning medication. On each occasion appropriate action was taken and further training was provided. We spoke to two members of staff and both demonstrated they understood and were confident in carrying out their responsibilities. We looked at the training records for three staff these show all of them have received refresher training this month. There are also records of checks being carried out on the competency of each staff member. However, the last recorded dates for these are September and October 2008. Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 Page 17 The manager is advised to re-introduce this to ensure procedures are being appropriately followed. Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 Page 18 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 & 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. The service has systems to ensure any concerns raised by people staying with them and other interested parties are listened to and acted upon. There are procedures in place to promote people’s well being and safeguard them from abuse. EVIDENCE: The service reports no complaints have been received by them since our last visit. It has a complaints procedure and this was last reviewed in January 2009. A copy of the procedure is displayed in the hall at the front of the premises. The information is also contained in the Statement of Purpose/Service User Guide. People we spoke to told us they had not had any reason to complain and were confident that any concerns or issues they did raise would be dealt with appropriately. Relatives also said they had not made any complaints, but were aware of the procedure and who they would speak to if they had any issues. There is a copy of the Department of Health guidelines regarding the Protection of Vulnerable Adults (POVA) and systems are in place to protect people from abuse. One member of staff told us they had received training, Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 Page 19 but this “was some time ago”. The training records we looked at for three staff show they last attended this course more than three years ago. However, staff we spoke with demonstrated they had a good understanding of the action needed to report any abuse they witness and/or allegations made to them. It is advisable for staff to receive periodic training to ensure they are updated and familiar with current good practice guidance. No safeguarding concerns have been reported by the service and none were raised during this visit. People have lockable facilities in their rooms where they can keep their own monies and/or other valuables. However, upon request staff will look after small amounts of monies for them. A system is in place to record incoming and outgoing of any monies given to the service to look after. Generally people are encouraged to take care of their own money and valuables where appropriate. People spoken to confirm they are provided with the key to the lockable facilities in their bedrooms. Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 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. The people who use this service stay in a homely, clean, safe and comfortable environment and where there are good arrangements for the prevention and control of infection. EVIDENCE: There is off-road parking available at the front of the premises. The rear garden is easily accessible to people who use wheelchairs with lawn and paved areas. At the side of the conservatory are some discarded items and arrangements should be made for these to be removed. The manager told us plans to make gardening more accessible to people who are interested have been forwarded to the company for approval. One person we spoke to said Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 Page 21 they enjoy the occasional barbecue. Staff told us this is organised in the summer when requested. Communal areas inside the premises include a lounge and spacious kitchen and dining area. People have unrestricted access to these areas and their bedrooms. However, supervision, where appropriate, is provided in high-risk areas such as the kitchen. A range of equipment is provided, such as grab rails and hoists, to promote independence and assist people with their mobility where required. The staff records we looked at show all three have received training to assist people to mobilise and the use of hoists. Since our last visit some improvements have been made. For example, the lounge has been re-decorated and the carpet replaced and the kitchen has been upgraded and a breakfast bar fitted. Bedrooms are suitably decorated and furnished and all have ‘free-view’ televisions. People are encouraged to bring any personal items they need for the period of their stay. We looked at one person’s bedroom with her/his permission. They said they had everything they needed including personal items such as family photographs and soft toys. There continues to be good systems in place for carrying out regular maintenance checks and environmental risk assessments. There is good information and appropriate storage arrangements for the control of substances hazardous to health. The staff team are trained in the prevention and control of infection and were observed following good hygiene practices. Relatives we spoke told us the premises were always clean and tidy whenever they visited. Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 35 & 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 suitable numbers of appropriately trained and competent staff so that their needs are met. Their well being is protected by the service’s recruitment practices. EVIDENCE: The staff team are made up of people who have different life experiences and. as previously, mentioned are all female. This is an issue the manager takes into consideration when appointing new staff. In the meantime, the service has access to experienced male members of staff from the relief team when required. Discussions with staff on duty show they are familiar with people’s needs, routines and how these are to be met. At the end of and beginning of each shift a hand over meeting is held. A staff communication book has been introduced to supplement these meetings. Staff told us this is a useful quick reference guide about what has been happening Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 Page 23 and informing them about events they need to read in more detail in a person’s daily notes or files. Information provided to us by the service show seven of eight staff hold the National Vocational Qualification (NVQ) Level 2 or above. Copies of these certificates are kept by the home. Staff reported they felt supported by the manager and received sufficient training to enable them to fulfil their roles and responsibilities. The training records show courses have been attended for client-centred issues, such as caring for people with epilepsy, dementia and Parkinson disease. However, although the service has been reviewing its assessment and care planning processes the training records we looked at show there has been no training in person-centred care planning nor has any been planned for the near future. It is recommended the staff team are provided with the training. The service’s recruitment records are maintained at its central head office and files requested where made available at the service on request. These contained completed application forms, references, interview notes and evidence that criminal record bureau (CRB) checks had been received prior to appointment. Suitable systems are in place for newly appointed staff to receive induction to the company and to the service. A record of this process, including weekly supervision with the manager, is kept on the person’s file together with a mandatory training programme. We looked at the supervision records for two staff and found that during the last twelve months one person has received supervision on four occasions and the other person twice. The standards recommend that each member of staff receives a minimum of six supervision sessions a year. The manager reported established staff lacked enthusiasm for regular supervision sessions. One staff told us they prefer to consult with the manager as and when they have any issues. Another said they found staff meetings more beneficial. We advised the manager to review the format and contents for individual supervision. People who use the service and their relatives tell us the staff team are “sensitive” to their needs and always “very helpful”. Two people told us they would not go anywhere else for a respite service. Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 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 who stay here benefit from having their needs met by a well run service. The service should further develop its quality assurance systems and produce an annual development for people to be fully confident their views underpin the service’s own self monitoring, review and plans for development. The health, safety and welfare of all people using this service are promoted and protected by its procedures and practice. EVIDENCE: Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 Page 25 The service is run by a suitably qualified and competent manager who states the aim of the service is to “Continue to work to our high standards always putting clients first”. She and her staff team are to be commended on the work undertaken to further develop the assessment and care planning processes for the people who use this service. The manager told us she identified her current training needs has being to update her knowledge and skills in recruitment, selection and supervision of staff and the deprivation of liberties safeguards for managers. Arrangements should be made with her line manager to discuss and plan periodic training to ensure these are being met. The records show a representative of the company regularly visits the service and produces a written record of her/his findings. The manager told us she finds these visits useful and there is evidence to demonstrate action is taken by the service to address any issues raised in the report. As well as the systems in place for obtaining the views of people who use the service, the service is advised to periodically seek the views of relatives and other interested parties. This should be incorporated into the quality assurance system for assessing its own performance. An annual development plan, based on the service’s findings, should be produced and made available to all interested parties so they can be fully confident their views underpin the service’s self-monitoring, review and plans for development. Basic first aid training is provided to all staff. Information provided by the service show there have been no serious accidents requiring visits to the accident & emergency department. This was confirmed as accurate by the manager and staff we spoke to. The staff team also undertake regular fire safety training and appropriate records are kept of checks carried out on fire alarms, lighting, exits and equipment. The records of when fire drills are carried show the last one took place in July 2009. People we spoke to told us they knew what to do in the event of the fire. Health and safety policies and procedures are periodically reviewed. We looked at the service’s records for routine checks carried out on the premises and servicing of appliances and equipment. These show suitable arrangements are in place to ensure the safety of all people on the premises. Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 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 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 3 32 4 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Version 5.3 Page 27 Alsop House DS0000041325.V377634.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. Refer to Standard YA20 Good Practice Recommendations A system for recording the handing over of the medication keys should be implemented to ensure these held by a person trained and authorised to manage people’s medication. The manager should re-introduce periodic competency checks for staff who handle medication to ensure procedures are being appropriately followed. Suitable arrangements should be made for staff to receive periodic training in protection issues to ensure they are update and familiar with current good practice guidance. Staff should be provided with training in person-centred care planning to assist them in reviewing practice. Staff should receive a minimum of six planned supervisions sessions every year to discuss practice to ensure the aims and objectives of the service are being met. Suitable arrangements should be made for the manager to DS0000041325.V377634.R01.S.doc Version 5.3 Page 28 2. 3. 4. 5. YA20 YA23 YA35 YA36 6. YA37 Alsop House 7. YA39 attend periodic training to up date her knowledge of current regulations and good practice guidance and support her further develop her management skills. A fully comprehensive quality assurance system should be implemented and annual develop plan produced so people can be fully confident their views underpin the service’s monitoring and review of its own practice. Alsop House DS0000041325.V377634.R01.S.doc Version 5.3 Page 29 Care Quality Commission Care Quality Commission West Midlands 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. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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