Care Home: Bishops Road, 172

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What the care home does well All of the residents are up to date with their person centred planning reviews, records looked at were relevant and up to date. We looked at two residents PCP reviews that were very informative showing photographs and pictures of what support each individual required. We spent a lot of time with three residents who were all very positive about their home, were told by the three residents that are happy living at Bishops Road. The environment is comfortable and homely for all of the residents, we had a full tour of the home and also spent time with three residents looking at their bedrooms all of which had their personal photographs, pictures and each bedroom was very comfortable. All three residents were very happy and proud to show us their bedroom. We looked at the weekly menu and discussed with the three residents, we were told that the food is good and that the residents will assist to do the shopping and help prepare the meals. We saw a lot of fresh fruit and vegetables at the home. Bishops Road, 172 DS0000019143.V376231.R01.S.doc Version 5.2 What has improved since the last inspection? We looked at the statement of purpose and service user guide, both documents have been up dated and are relevant to the home informing prospective residents and the people that use the service of what the aims and philosophy of the home are. We looked at the finance procedure at the home. The acting manager is monitoring the financial transactions of all residents monies on a weekly basis. We checked the records of two residents that had the correct money and financial transaction information in place. We spent time discussing the registration of the acting manager with the CQC. This was a requirement in 2008 for the last manager of Bishops Road. The acting manager told us that he has started his registration with the CQC. We looked at the fire evacuation risk assessments for all four residents that are now in place and are reviewed regularly. We looked at a lot of documentation and records all were seen to have a date recorded on them. What the care home could do better: One of the residents living at the home is now requiring more staff support their health has deteriorated and their mobility is now poor. We spent time discussing the staffing with the acting manager who told us that it is difficult as staff is spending more time with this resident and the other three residents are at times not able to participate in activities in the community. We discussed the acting manager liaising with the commissioning local authority to look at the change in care now provided by the staff at Bishops Road. We looked at the medication record sheets for three residents; one of the residents had not received their evening medication from the previous evening. We spent time discussing this with the member of staff. This incident was reported to the relevant professionals and NHS direct who confirmed that the resident would not be in any danger because of the medication omission.Bishops Road, 172DS0000019143.V376231.R01.S.docVersion 5.2One of the residents is prescribed warfrin, the dosage changes on a Sunday however the same amount was seen in the monitored dosage system. We looked at the medication record sheet that had no information recorded as to what the procedure was. We were told that the pharmacy provides the extra tablet as the dosage changes regularly. The staff member told us that the extra warfrin tablet is put in a bottle and the tablets are returned to the pharmacy on a monthly basis if not required. We looked at the records from weekly residents meetings, there was an entry made in May 2008 of a resident complaining about a bank member of staff that upset her. We spent time talking to the acting manager about the information and informed the acting manager that this should initiate a safeguarding meeting and the relevant professionals must be informed. We looked at supervision records and spent time talking to the acting manager and a member of staff. We were told that because there is no deputy manager at the home supervision meetings with staff are not happening as regularly as they should. We spent time in three of the residents bedrooms. We checked the hot water temperatures in each room all were cold. We looked at the water temperature records taken over the last few months that show there is a problem with the hot water supply to all residents bedrooms. The acting manager told us that he has reported the problem numerous times to the organisation and the landlords. We looked at the records sent by the manager to the organisation and their response. The residents told us that they are not happy about the hot water in their bedrooms being cold. Policies and information looked at on the notice board was in some instances in small print, it would benefit residents and visitors if the wording was enlarged in easy to read format. Key inspection report CARE HOME ADULTS 18-65 Bishops Road, 172 Bishops Road 172 Bishops Road Fulham London SW6 7JG Lead Inspector Jacqueline Derbyshire Key Unannounced Inspection 2nd July 2009 09:00 Bishops Road, 172 DS0000019143.V376231.R01.S.doc Version 5.2 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. Bishops Road, 172 DS0000019143.V376231.R01.S.doc Version 5.2 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 Bishops Road, 172 DS0000019143.V376231.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bishops Road, 172 Address Bishops Road 172 Bishops Road Fulham London SW6 7JG 020 7371 7808 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) jonathan.parkin@yarrowhousing.org.uk Yarrow Housing Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Bishops Road, 172 DS0000019143.V376231.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: 4 26th September 2007 Date of last inspection Brief Description of the Service: 172 Bishop’s Road provides accommodation and support for four women with a learning disability, allowing them to lead as independent a life as possible in the community. The house is of 2 storeys, in a quiet residential road. The house is well maintained and attractively furnished and provides a comfortable home for the four people who live there. A programme of day activities is arranged for each resident, using local community and specialist resources. Care and support is provided by Yarrow Housing Ltd. The building is owned and maintained by the Notting Hill Housing Trust. Bishops Road, 172 DS0000019143.V376231.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 adequate quality outcomes. Throughout this report the word we will be used as meaning the Care Quality Commission CQC. This unannounced inspection took place on Thursday 2nd July 2009; we spent 4.00 hours visiting the home. We were assisted by an expert by experience who is a person because of their shared experience of using services, visits with an inspector to help them get a picture of what it is like to live there. We spent time talking to three of the four residents, the acting manager and a member of staff. We checked the care records of two residents and all medication and finance records were looked at. We had a full tour of the home and looked at three residents bedrooms. Bishops road was in a good state of repair and residents told us they are happy with the décor in the home. We received four residents surveys and a one staff survey, comments from the surveys will be included throughout this report. 5 requirements set in September 2008 have all been fully met, 6 new requirements have been set from this inspection. We will make reference to the AQAA Annual Quality Assurance Assessment throughout this report. The weekly fee for the home is £1022. What the service does well: All of the residents are up to date with their person centred planning reviews, records looked at were relevant and up to date. We looked at two residents PCP reviews that were very informative showing photographs and pictures of what support each individual required. We spent a lot of time with three residents who were all very positive about their home, were told by the three residents that are happy living at Bishops Road. The environment is comfortable and homely for all of the residents, we had a full tour of the home and also spent time with three residents looking at their bedrooms all of which had their personal photographs, pictures and each bedroom was very comfortable. All three residents were very happy and proud to show us their bedroom. We looked at the weekly menu and discussed with the three residents, we were told that the food is good and that the residents will assist to do the shopping and help prepare the meals. We saw a lot of fresh fruit and vegetables at the home. Bishops Road, 172 DS0000019143.V376231.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: One of the residents living at the home is now requiring more staff support their health has deteriorated and their mobility is now poor. We spent time discussing the staffing with the acting manager who told us that it is difficult as staff is spending more time with this resident and the other three residents are at times not able to participate in activities in the community. We discussed the acting manager liaising with the commissioning local authority to look at the change in care now provided by the staff at Bishops Road. We looked at the medication record sheets for three residents; one of the residents had not received their evening medication from the previous evening. We spent time discussing this with the member of staff. This incident was reported to the relevant professionals and NHS direct who confirmed that the resident would not be in any danger because of the medication omission. Bishops Road, 172 DS0000019143.V376231.R01.S.doc Version 5.2 Page 7 One of the residents is prescribed warfrin, the dosage changes on a Sunday however the same amount was seen in the monitored dosage system. We looked at the medication record sheet that had no information recorded as to what the procedure was. We were told that the pharmacy provides the extra tablet as the dosage changes regularly. The staff member told us that the extra warfrin tablet is put in a bottle and the tablets are returned to the pharmacy on a monthly basis if not required. We looked at the records from weekly residents meetings, there was an entry made in May 2008 of a resident complaining about a bank member of staff that upset her. We spent time talking to the acting manager about the information and informed the acting manager that this should initiate a safeguarding meeting and the relevant professionals must be informed. We looked at supervision records and spent time talking to the acting manager and a member of staff. We were told that because there is no deputy manager at the home supervision meetings with staff are not happening as regularly as they should. We spent time in three of the residents bedrooms. We checked the hot water temperatures in each room all were cold. We looked at the water temperature records taken over the last few months that show there is a problem with the hot water supply to all residents bedrooms. The acting manager told us that he has reported the problem numerous times to the organisation and the landlords. We looked at the records sent by the manager to the organisation and their response. The residents told us that they are not happy about the hot water in their bedrooms being cold. Policies and information looked at on the notice board was in some instances in small print, it would benefit residents and visitors if the wording was enlarged in easy to read format. 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. Bishops Road, 172 DS0000019143.V376231.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 Bishops Road, 172 DS0000019143.V376231.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 and 5. 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 home provides a statement of purpose that is specific to the individual home and the resident group they care for. EVIDENCE: Comments from residents. I like living here ‘I like the staff, I am happy living here’. ‘I like it here and I like my room’. We looked at the statement of purpose and service user guide, the documents have been updated and include all information on the aims and objectives and philosophy of acre provide at Bishops Road. We looked at records in two resident’s files that show that their needs are assessed and reviewed regularly. All of the people living at the home have been there for a long time. We looked at person centred plans were with risk assessment records that worked in conjunction with the PCP records. Bishops Road, 172 DS0000019143.V376231.R01.S.doc Version 5.2 Page 10 We discussed the changing needs of the residents as one resident will be 82 imminently and we were told that their health and mobility is deteriorating. The resident was in hospital at the time of this inspection. We were told by the acting manager that the resident does require a lot more staff time to assist with all personal care tasks and when going out into the community. We were told that staffing levels can become a problem especially for the other three residents as they cannot be provided with the relevant staff input to attend activities in the community or in the home. We looked at two resident’s agreements; the records were up to date and are reviewed annually. Both records were signed and dated by the residents. All original contracts are kept at the Yarrow head office. Bishops Road, 172 DS0000019143.V376231.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. The service will know and record the preferred communication style of the individual, and will use proven methods that enable the person to lead a full life that promotes independence and choice. Staff understand the importance of all residents being supported to take control of their own lives. EVIDENCE: Comments from residents. I am helped by staff but I am able to do my own personal care. ‘The staff help me; I like all of the staff’. Bishops Road, 172 DS0000019143.V376231.R01.S.doc Version 5.2 Page 12 We looked at two residents files, both included person centred plans with lots of reviewed records. The PCP plans are informative and relevant to each individuals needs. The PCP plans do reflect the aims and aspirations of the residents; one showed that the individual would like to go on holiday again with the other residents. Another resident had that they would like to go visit their relative; records show they do this on a regular basis. The PCP plans do reflect the individual’s health and social care needs and how the staff are meeting each persons needs. The PCP’s were in pictorial formats, showing how the individuals are involved in their person centred plans. All three residents in the home at the time of this inspection were seen to be helping themselves to food and drink in the kitchen. All three residents told us that they choose what to wear and each resident looked very smart. Staff was seen to promote the residents independence assisting them when requested and not telling the residents what to do. We looked at the risk assessments for two residents, all of the risk areas identified in the care plan had an action plan in place to inform staff of the risk and how to eliminate or minimize the risk. The risk assessments did work in conjunction with the care plans. We also looked at all four resident’s fire evacuation risk assessments. We saw a lot of reviewed risk assessments that did reflect any change in the residents care needs. Bishops Road, 172 DS0000019143.V376231.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): This is what people staying in this care home experience: Standards 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. Residents are involved in meaningful daytime activities of their own choice and according to their relevant interests, diverse needs and capabilities. EVIDENCE: Comments from residents and staff. I do a lot of activities. I would like the manager to take me out more. ‘I like the food, I help to cook sometimes’. ‘The home provides good food we choose the meals’. Bishops Road, 172 DS0000019143.V376231.R01.S.doc Version 5.2 Page 14 We looked at the person centred plans of two residents; the records contained a lot of information about each resident’s likes, dislikes, hobbies and leisure interests. We also looked at the daily records for all four residents that had information about what activities they had done daily that included going to the local community centre called the Gate, attending dancing classes, art classes, discos and eating out. We discussed religious beliefs with the acting manager and were told that none of the residents want to attend any religious services in the community. We discussed a comment made in a survey with the acting manager returned to the CQC stating that one of the residents would like him to take them out. We were told that the resident does attend activities in the community however they liked the acting manager to take them out. We looked at the activity programme for all four residents that show they all do attend activities in the local community. As stated in this report because of the diminishing health of one resident at times they require more staff input and this can impact on the other residents. We were told by the acting manager that there are difficulties in escorting residents out as one resident now requires one-one staff input most of the time. We looked at the rota for staffing in June 2009 that shows there is a need for more staff to provide appropriate activities for all residents. There is a vacancy at the home that is covered by the acting manager and staff doing overtime. The expert by experience spent time discussing the activity programme with all three residents who stated they are happy with the activities provided. We looked at the contact information for two residents, two residents contacts their families on the telephone on a regular basis and also visit them in their homes. Their families also visit Bishop Road. In discussion with the acting manager we were told that residents are always encouraged to continue relationships with their family and friends. We were told by the acting manager that the big shopping is done weekly and staff and residents will shop more regularly for perishable items. The three residents at the home told us they help with the shopping. We saw a lot of fresh food at the home. We were told by residents that they enjoy the food, all three residents were seen to help them self to breakfast and hot drinks when they wanted them. None of the residents require a special diet, the menu was seen to be varied and nutritious, residents choose the menus at their weekly house meeting. Bishops Road, 172 DS0000019143.V376231.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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 receive personal and healthcare support using person centred approach with support provided based upon the rights and dignity, equality, fairness, autonomy and respect. Personal healthcare needs including specialist health; nursing requirements are clearly recorded in each person centred plan. The home has a medication policy that all staff must be trained to follow. EVIDENCE: Comments from residents. ‘The staff are nice they help me when I ask’. ‘I get on with all of the staff’. Bishops Road, 172 DS0000019143.V376231.R01.S.doc Version 5.2 Page 16 We looked at two residents files, both included information on what level of support they require. On the day of this site visit staff were seen to be encouraging the residents. Personal and healthcare support is provided in a person centred way. All four residents require different levels of support from full support to prompting an individual; the information was clear in each PCP plan looked at. We saw information on how the home had liaised with other professionals including speech and language therapists, psychologists, psychiatrists and social workers. One resident whose health and mobility has deteriorated requires more staff in put; we were told by the acting manager that he will liaise with the commissioning local authority as the individuals care needs have changed. The information in the residents support plans is informative and up to date. All of the residents living at Bishops Road are registered with a local GP. We looked at the medication records for three residents, on the day of this inspection the previous evening medication had not been administered by the night staff. We discussed the omission with the member of staff who contacted the NHS direct to get advice. We looked at the storage of medication that is in the kitchen/dining room. One of the residents is prescribed warfrin, the dosage changes on a Sunday however the same amount was seen in the monitored dosage system. We looked at the medication record sheet that had no information recorded as to what the procedure was. We were told that the pharmacy provides the extra tablet as the dosage changes regularly. The staff member told us that the extra warfrin tablet is put in a bottle and the tablets are returned to the pharmacy on a monthly basis if not required. The acting manager must make sure that the medication records are completed appropriately to show the procedure followed at the home. We looked at staff training records and all staff has attended medication training. Bishops Road, 172 DS0000019143.V376231.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand. It is available in different formats to help anyone staying at or involved with the service to complain or make suggestions for improvement. EVIDENCE: Comments from residents. I will speak to staff if I am not happy. ‘I will speak to the manager if I have a complaint’. We looked at the complaints file that had one complaint logged that was written by the acting manager on behalf of all the resident relating to the problem of them having no hot water in their bedrooms. We were told by the acting that all staff is aware of what to do if a complaint or issue was raised. The complaints procedure was on the resident’s notice board in the hallway. The complaints procedure is available in different formats including pictorial. Bishops Road, 172 DS0000019143.V376231.R01.S.doc Version 5.2 Page 18 We spent time discussing the safeguarding policy and procedure with the acting manager. When looking at the weekly residents meeting records there was an entry in May 2009 that stated one of the residents was upset and was crying because of a member of staff. We asked the acting manager if this had initiated a safeguarding investigation. We were told the member of staff was told they could no longer work at the home. We told the acting manager that this must initiate a safeguarding investigation and the relevant local authority must be informed. The acting manager has put in place the organisations safeguarding policy and procedure and the local authority procedure for staff to follow if an incident occurs. We looked at the training records of all staff and all staff except one has attended safeguarding training. Bishops Road, 172 DS0000019143.V376231.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 28 and 29. 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 standard of home is reflected in the statement of purpose, it is comfortable and homely. Residents are encouraged to personalize their own bedrooms. All of the homes fixtures and fittings meet the needs of individuals and can be changed if their needs change. The home is not accessible for people with a physical disability as there is no lift to access upper level floors. EVIDENCE: Comments from residents and staff. I am happy with my bedroom. I like my bedroom . Bishops Road, 172 DS0000019143.V376231.R01.S.doc Version 5.2 Page 20 ‘I love my bedroom’. ‘The home creates a warm welcoming environment for service users, staff and family and friends’. We had a full tour of the home and all areas were seen. We looked at all of the communal areas that were comfortable and well decorated. Bishops Road is comfortable and homely for all of the residents, we spent time with three residents looking at their bedrooms all of which had their personal photographs, pictures and each bedroom was very comfortable. All three residents were very happy and proud to show us their bedroom. We were told by the three residents that they are happy with the decor. The home was clean, tidy warm and bright on the day of this site visit. The expert by experience spent time having a tour of the home with all three residents that told him they love the home and would not change anything. Bishops Road, 172 DS0000019143.V376231.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34, 35 and 36. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is not enough staff available to meet the needs of all residents due to the change in health of one individual. EVIDENCE: Comments from residents and staff. The staff are nice they help me. I am very happy with the staff. I am happy working at Bishops Road’. We looked at the staff rota for June 2009, there was adequate staffing on each shift to meet the care needs of the four residents, however there is not sufficient staffing to provide a full activity programme for all residents especially trips into the local community. Bishops Road, 172 DS0000019143.V376231.R01.S.doc Version 5.2 Page 22 As stated throughout this report one resident’s health and mobility has deteriorated and we were told that the individual requires a lot more support. We spent time discussing staffing with the acting manager and were told that there is a deputy manager vacancy in Bishops Road. The acting manager is liaising with the organisation and the commissioning local authority as there is a need for more staffing hours in the home to meet the needs of all of the four residents living there. We were told by residents that they liked all of the staff. We looked at the CRB information on all staff and bank staff currently working at Bishops Road, all disclosures were up to date. We looked at the training records of all staff that show that all staff is up to date with training, there is one member of staff currently going through the induction programme, we saw the training plan for this member of staff that shows they will attend all relevant training. We spent time at the organisations head office in December 2008 looking at staff recruitment records, all of the relevant checks were seen to be in place. All staff recruitment records are kept by the human resources team in safe storage at the head office. The acting manager is registered to commence an NVQ level 4 in September 2009. We spent time discussing the continuous training of all staff with the acting manager who told us all staff is up to date with training. Records were looked at showing that staff is attending training and keeping up to date in the organisations training programme. There are currently three members of staff with an NVQ. Bishops Road, 172 DS0000019143.V376231.R01.S.doc Version 5.2 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): Standards 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. There is not enough staff available to meet the needs of all residents. Staff rotas do not take into account the activity needs of the people using the service. EVIDENCE: The acting manager has worked in social care for many years and is very experienced; the acting manager is registered to commence training to complete an NVQ level 4 in September 2009. Bishops Road, 172 DS0000019143.V376231.R01.S.doc Version 5.2 Page 24 We spent time throughout this site visit discussing all areas of running the home, the acting manager is very positive about the care provided by the staff team and discussed the person centred approach that all staff follow making sure all three residents independence is promoted. All three residents spoken with were very positive about the acting manager and were all seen to be very positive about the support given to them by all staff. We spent time discussing the organisations quality assurance procedure with the acting manager. We looked at questionnaires that hade been completed by residents, advocates and other professionals that work with the residents. We saw a lot of positive comments about the care provided at Bishops Road. The organisation produces an annual survey of all of the homes including Bishops Road. We were given information in the AQAA returned that shows that all health and safety checks are completed on a regular basis. We looked at records for checks for the fire alarm system, tests and evacuation records, safe food storage, water temperatures and gas and electric maintenance, all were seen to be well recorded and up to date. All staff training records were looked at and all staff has completed first aid training, we were told by the acting manager that the member of staff will be attending all relevant training imminently. Bishops Road, 172 DS0000019143.V376231.R01.S.doc Version 5.2 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 3 2 3 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 x 27 x 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 3 36 2 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 x 3 x x 2 x Version 5.2 Page 26 Bishops Road, 172 DS0000019143.V376231.R01.S.doc No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 YA33 Regulation 13 Requirement The acting manager to liaise with the commission local authority to assess and provide relevant funding for a resident whose care needs have changed and more staff input is required. The acting manager to make sure that all staff are following the correct medication procedure and have had the appropriate training to safeguard all residents. The acting manager to make sure that all staff is correctly recording information on the medication record for the resident that is administered warfrin medication. The acting manager must report the incident from the residents meeting record to the relevant professionals to make sure that all residents are protected. The acting manager must make sure that all staff is receiving the relevant level of supervision meetings to make sure they are meeting the organisations aims DS0000019143.V376231.R01.S.doc Timescale for action 02/08/09 2 YA20 13 02/08/09 3 YA20 13 07/08/09 4 YA23 13 07/07/09 5 YA36 18 02/09/09 Bishops Road, 172 Version 5.2 Page 27 and objectives as well as their own. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bishops Road, 172 DS0000019143.V376231.R01.S.doc Version 5.2 Page 28 Care Quality Commission 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). 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