Care Home: Collinson Court

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What the care home does well The service provides information for people wishing to use the service and those that use the service in a user-friendly format and offers a safe service for those people with a learning disability and who may have Autism Spectrum Disorder and or Aspergers Syndrome. The service provides accommodation in a purpose built single storey building, which is divided into 2 single occupancy flats and 2 apartments that can each accommodate 4 people. The environment is pleasant and generally well maintained. People who use the service have been involved in decisions about the place they live in. Care plans are detailed and risk assessments relating to the individual needs of people who use the service are of a good standard with evidence that they have been reviewed regularly. People who use the service are being supported to be more involved in decision-making about their lives. People who use the service know their health needs are known and they will be supported to access the health service they need. Medication records are usually accurate and storage of medication satisfactory. There is a clear and transparent complaints procedure in place and people who use the service know how to complain if they need to. They can also be confident that staff know what to do to ensure that people who use the service are protected from abuse. The manager is registered with us and approved as a fit person to manage the service. The numbers of staff trained to NVQ level 2 and above is high. The frequency of staff supervision is satisfactory and staff feel supported by the management team. Policies and procedures reflect the needs of the service and the people who live there. The service ensures that the diverse needs of staff and people who use the service are respected. What has improved since the last inspection? Information in the AQAA tells us that, "The environment has improved, a sensory room has been completed and is used daily. Improved recreational activities for the service users. Improved service user guide and statement of purpose. Improved terms and conditions of residency. A happier staff team who create a more pleasant environment for the service users. Better understanding of behavioural management." We have noted that people who use the service who are being supported to be involved in the writing of new format PCCP, (person centred care plan) files. The manager of the home is now registered and approved by us. Systems for the administration and management of medication have been improved, and although there have been a number of medication errors, the manager has demonstrated that she has managed these effectively and the frequency of errors has reduced. Redecoration to communal areas and some bedrooms has been competed. CARE HOME ADULTS 18-65 Collinson Court 56 Longton Road Trentham Stoke-on-trent Staffordshire ST4 8ND Lead Inspector Wendy Jones Unannounced Inspection 18th September 2008 10:20 Collinson Court DS0000008324.V370539.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 Collinson Court DS0000008324.V370539.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. Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Collinson Court Address 56 Longton Road Trentham Stoke-on-trent Staffordshire ST4 8ND 01782 658156 01782 643103 collinson.court@craegmoor.co.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) Autism Tascc Services Limited Ms Denise Jean Stevens Care Home 10 Category(ies) of Learning disability (10), Mental disorder, registration, with number excluding learning disability or dementia (10) of places Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th September 2007 Brief Description of the Service: Collinson Court is a purpose-built care home, registered to provide accommodation for 10 adults. The home provides a specialist service to people with an autistic spectrum disorder. The primary diagnosis of people using the service must be learning disabilities although they may have a dual diagnosis of a mental health condition. The property provides ground floor accommodation divided into four areas, each with its own entrance. These consist of two four-person apartments, two single-person flats, a staff office, training area, activity room and gym. Each apartment and flat has its own garden area and the gardens to the rear of the property are secure. The home is located off the main Trentham to Longton road; it provides off-road parking and shared drive access. The building is single-storey, providing access to wheelchair users. The Service User Guide does not contain information about the range of fees and the additional costs of the service. People who may wish to use this service and their supporters should contact the provider for this information. Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection site visit of this service undertaken on 18 September 2008 and included feedback to the manager. In total the visit took approximately 6:00 hours. The purpose of this visit was to assess the services performance and to establish if it provides positive outcomes for the people who live there. The visit included checking that any requirements and recommendations of the previous inspection visit of 18/09/07 have been acted upon; looking at information the service provides for people wishing to use the service, their carers and any professionals and looking at the information that the service provides to people who use the service to ensure that they understand the terms and conditions under which they have agreed to live at the home and the fees they should pay. Other information checked included assessments and care records, health and medication records; activity and records relating to the menu’s, finances, staff training and recruitment, complaints and compliments, fire safety and health and safety checks. The manager, staff and people using the service were spoken to during the site visit and a brief tour of the building was undertaken. Before the visit began, the service provided it’s own assessment of its performance, in the form of an Annual Quality Assurance Assessment (AQAA). Surveys were sent out to people using the service, relatives, staff and any professional that has involvement in the service. Eight surveys from people using the service and seven staff surveys have been received. The people using the service have been supported and assisted by the care staff to complete the surveys. The main points are included in this report. As a result of this visit we have made 8 recommendations What the service does well: The service provides information for people wishing to use the service and those that use the service in a user-friendly format and offers a safe service for those people with a learning disability and who may have Autism Spectrum Disorder and or Aspergers Syndrome. The service provides accommodation in a purpose built single storey building, which is divided into 2 single occupancy flats and 2 apartments that can each accommodate 4 people. The environment is pleasant and generally well maintained. People who use the service have been involved in decisions about the place they live in. Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 6 Care plans are detailed and risk assessments relating to the individual needs of people who use the service are of a good standard with evidence that they have been reviewed regularly. People who use the service are being supported to be more involved in decision-making about their lives. People who use the service know their health needs are known and they will be supported to access the health service they need. Medication records are usually accurate and storage of medication satisfactory. There is a clear and transparent complaints procedure in place and people who use the service know how to complain if they need to. They can also be confident that staff know what to do to ensure that people who use the service are protected from abuse. The manager is registered with us and approved as a fit person to manage the service. The numbers of staff trained to NVQ level 2 and above is high. The frequency of staff supervision is satisfactory and staff feel supported by the management team. Policies and procedures reflect the needs of the service and the people who live there. The service ensures that the diverse needs of staff and people who use the service are respected. What has improved since the last inspection? Information in the AQAA tells us that, “The environment has improved, a sensory room has been completed and is used daily. Improved recreational activities for the service users. Improved service user guide and statement of purpose. Improved terms and conditions of residency. A happier staff team who create a more pleasant environment for the service users. Better understanding of behavioural management.” We have noted that people who use the service who are being supported to be involved in the writing of new format PCCP, (person centred care plan) files. The manager of the home is now registered and approved by us. Systems for the administration and management of medication have been improved, and although there have been a number of medication errors, the manager has demonstrated that she has managed these effectively and the frequency of errors has reduced. Redecoration to communal areas and some bedrooms has been competed. Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 7 What they could do better: 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. Collinson Court DS0000008324.V370539.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 Collinson Court DS0000008324.V370539.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who wish to use the service have access to information about it in a form that they can easily understand, but do not have the information about the range of fees and costs. This means they cannot make a properly informed decision about moving in to the home. They can be confident that their care needs will be properly assessed, before they move in and therefore that the home knows what support they are going to need. EVIDENCE: A Statement of Purpose is on display in the main foyer of the building and was updated in August 2008. The Service User Guide has been produced in a userfriendly format, but needs to include the range of fees and the costs of the service. The manager says that all people using the service have contracts and the terms and conditions of their residency in their personal files. This was evidenced in the sample of 2 care files we looked at. People who use the service said, “I received information about the home before moving in.” No-one has been admitted to the home since the last key inspection visit and as identified in previous reports, assessment information is detailed and supported by information from other professionals. Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 10 Collinson Court DS0000008324.V370539.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that they will be included in discussions about their care and supported to make their own decisions as much as possible. This approach provides evidence that the service values them as individuals. EVIDENCE: The service told us in the AQAA that, “We encourage 1:1 time between service users and staff, particularly key and co-workers, hold monthly service user meetings (in a format they can participate in eg. Makaton, pictures), one service user attends bi-monthly ‘Your Voice” area meetings, service user surveys, and service user involvement in the writing of the new PCCP files.” The service has introduced a Person Centred Planning, (PCP) model since the last inspection, it is hoped that this method will support staff to be more focussed on individual needs and facilitate better record keeping. Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 12 Staff said, “It has taken some time to get used to but the information we have is relevant and up to date,” and, “I have had the opportunity to look at the plans for the service users I will be working with, and feel they have provided me with a good insight into their needs.” The manager said that at the moment, one person is being supported to be actively involved in planning her care, and goal setting. This will be extended to other people using the service as the staff team become more confident in using the new model and approach to care planning. People using the service said in surveys, “I like living at Collinson Court. The staff are always nice to me.” We looked at 2 care files for people using the service, all contained relevant information including Service User Guide/Statement of Purpose, a contract, including terms and conditions of residency, full assessments, support plans and risk assessments. There is evidence that support plans are reviewed, which means that staff have up to date knowledge of people’s care needs and how to support them. Collinson Court DS0000008324.V370539.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): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that the staff know what their goals and aspiration are, but cannot be sure that they have opportunities to become engaged in meaningful activities in or out of the home on a regular basis. EVIDENCE: The service told us in the AQAA that, “We are continuing to offer a wider range of activity opportunities and source a suitable holiday venue, (a suitable one was identified but is no longer accepting bookings), in the mean time day trips are being planned. We are working towards one service user regaining family contact. We are trying to identify a suitable further education facility/course for one service user who is currently attending year three of college. This college will be unable to offer a place next year. We hope that one service user will re-attend Dragon Square, a specialist day centre.” Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 14 We looked at the records of two people using the service and noted from the sample that activity outside of the home is limited and the types of in-house activity in the home is generally passive. The manager said that people using the service have been involved in more activity out of the home, including weekly visits to an Adult Adventure scheme, but this is not available during the school holidays. One person attends college for three sessions per week; one person represents the service at forum meetings for people using the service, arranged by the company. All people using the service have opportunities to discuss their care, social and recreational needs with their key worker. We have been told that people using the service enjoy using the now completed sensory room and that staff feel that it is a real asset. From the sample of records seen we could find some evidence of regular use. People using the service told us in the surveys that, “We can do what we want to during the day.” A member of staff said, “I have observed staff routinely trying to engage service users in activities and always offering opportunities to do things, I feel that there should be more opportunities to go out of the home with service users but staffing levels can limit this.” We observed, one person using the service reading magazines and were told that 3 other people were listening to music or watching DVD’s in their bedrooms. We saw one person being engaged in an activity in another unit. Each of the units has their own kitchen area where they can be supported to help with food preparation and making drinks, subject to risk assessment. Staff explained that menus are devised on a weekly basis; this helps with food shopping and is usually based upon the known preferences of people using the service. A choice of main meal is always available; this is evidenced on the records. We did not observe a mealtime during this visit. Collinson Court DS0000008324.V370539.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that their health care needs are known met and monitored and that action has been taken and continues, to make sure that they receive the medication they need. EVIDENCE: The service told us in the AQAA that, “All staff attend equity and diversity training and are aware that there is a zero tolerance policy for any form of discrimination. We have a non-discriminatory recruitment policy and our staff team reflects society as far as possible.” Records show that the health needs of the people using the service are known and recorded and that they have access to regular health checks and appointments. Most of the people using the service also have access to specialist health services and regular reviews of their needs are undertaken with the consultant psychiatrist responsible for doing this. A sample of the care records shows that the service has initiated Health Action Plans, these details the specific health needs of the individual and the action Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 16 the service needs to take to ensure those needs are met. We saw evidence that people using the service have attended preventative health care appointments. Comments in staff surveys said, “The service has improved since we have had a new manager who understands the health needs of service users. Behaviour management strategies are working well and negative behaviours have decreased.” We looked at the information we have been provided with since the last key inspection and were concerned by the number of medication errors that have been reported to us. We spoke to the manager about this who confirmed the number of errors and also said that staff have received training and have been assessed as competent. On each occasion a medication error is reported it is discussed with the staff member involved, and retraining is offered. The service has also now adopted a stricter approach for more than one medication error; this means that staff will no longer be able to administer medication. This directly affects their role and therefore is taken seriously. The manager stated that she feels that this approach has improved practice. The evidence we have is that since May 2008 there have been fewer medication errors. The medication records we saw show good practice in relation to medication record keeping, but there was some confusion during this visit about the amounts of medication stock against the amount in the medication record. But it was eventually confirmed that no error had occurred. A member of staff explained that stock levels are checked daily as per the service’s new procedure and that this can take some time. Since the key inspection visit the manager has said: “Regarding the Medication Stock Count: I have been considering the most effective way to ensure correct stock counts, I am putting the following into place: A new improved stock count form will be used that is a little more straight forward and user friendly, a dedicated time will be used for stock counts, this is during the afternoon handover time when extra staff are in the building. The next staff meeting will include a training session for all staff regarding how to do a stock take and why it is important. Stock counts will be discussed in the next supervisions for all staff that administer medication. Staff will also be informed that not carrying out the stock count as per policy and procedure is a disciplinary matter.” We also looked at the protocols for ‘as required’, (PRN) medication; these give the detailed instruction to staff about when medication of this type can be administered. We have noted that there is some discrepancy in the information in two protocols and the prescription instructions, for ‘as required’ paracetamol, and in one instance a person has been prescribed ‘as required’ Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 17 chlorpromazine with no evidence of a protocol in place. These issues must be rectified. Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be sure that the complaints procedure is available to them in a format they can understand and that staff are committed and trained to ensure their safety and protect them from abuse. EVIDENCE: The service told us in the AQAA that, “We implement a robust complaints procedure as per company policy. Complaint/comments cards now on display in foyer for visitors to complete. Implementation of POVA procedure with multi agency involvement when required. We encourage service users, family and visitors to provide feedback regarding the service we provide by regular contact and surveys.” Three people using the service said in the surveys that they know who to go to if they have any concerns, five did not comment. In surveys, all staff said they knew what to do if they received a complaint about the service. We have not received any complaints about this service but have been made aware of two safeguarding referrals since the last key inspection visit. The manager has demonstrated a clear commitment to the protection of people using the service by promptly reporting suspected safeguarding issues and cooperating fully with any enquiries. Both issues have now been resolved. And action taken to ensure people’s safety and well being for the future. Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 19 Recruitment procedures include requesting pre employment checks such as Protection of Vulnerable Adults register (POVA), and Criminal Records Bureau (CRB). We discussed the need to ensure that any gaps in employment history are discussed with any prospective employee and one of the two written references should be from the last previous employer. The organisation has it’s own Human Resources department and also uses an employment agency to assist with staff recruitment. The service keeps us informed of event in the home including accidents and incidents. Since the last inspection we have received 8 notifications of medication errors that have occurred at the home. We have discussed all of these matters with the manager and are satisfied that she has taken the necessary action to seek advice following each error, including consultation with the GP or emergency health services. And subsequently looked into the circumstances of each medication error and made changes to the procedures to reduce the risk of this happening again. The evidence we have is that there does seem to be an improvement in this area. And the records of the staff meeting dated 02/09/09 show that staff have been reminded of the importance of vigilance in this area for the benefit of people using the service. Six of the reported errors were from 29/01/08 to 06/04/08 and two incidents during the period from 07/07/08 and 03/09/08. The manager has stated that she has received one formal complaint since the last key inspection; this did not directly relate to care of people using the service, records made available confirmed this. We understand that all staff have received or are booked to receive training relating to recognising and reporting suspected abuse of people using the service. Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service have a home that is generally well maintained and provides a comfortable environment in which to live. Regular maintenance checks are undertaken to ensure the home is safe. EVIDENCE: The service told us in the AQAA that, “Improvement of the internal physical environment has taken place providing a welcoming, friendly and pleasant environment, free from odour. Regular internal and external maintenance checks are carried out. We provide a safe environment for service users, staff and visitors and have systems in place to identify and manage maintenance needs.” We observed that the majority of the environmental works commissioned by the organisation have now been completed; outstanding issues include the exterior of the property. The manager said that she has been told that the work to complete this will take place within the next two weeks. Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 21 During this visit we saw a single person flat that has been redecorated since the last key visit and confirmed with the person living there that he is happy with the results and had been involved in choosing the colour scheme. We saw that Apartment 1 is in a good state of repair, although the main hall carpet is stained in places, i.e. outside the kitchen and outside the shower room. The bathroom has been upgraded but requires some further work to make it a pleasant and welcoming environment in which to bathe. We saw Apartment 2 and noted an odour; this was discussed with the member of staff on duty for attention. We have been told that a new sofa has been ordered to replace one that has been broken. Again general observation shows this unit to be clean and well maintained. We also saw one bedroom that confirmed this. Issues that continue to need attention include some damp areas that we were told relate to the outstanding works to the exterior of the building. Each of the Apartments has a small kitchen where staff and people using the service can prepare and make drinks and meals; risk assessments are in place to ensure service user safety. Since the last inspection the ventilation fans have been repaired and we understand that work is being carried out to ensure that the air conditioning system works properly. Each of the flats is for a single occupant and provides spacious living and private space including en-suite facilities. Efforts have been made to improve the privacy for people using the service in the gardens by having wooden fencing fixed to railings to the side of the home and trellis and planting to the front garden. The main entrance is welcoming and pleasant with lots of information about the service including the Statement of Purpose, complaints procedure, comments book, visitors book and seating. Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service feel confident that staff have the induction and access to basic training to meet their needs, but must also be confident that all staff receive training specific to the needs of the people using the service. EVIDENCE: The service told us in the AQAA that, “We have a good male/female staffing ratio and staffing levels and we now have a fully staffed home. We have implemented a robust recruitment policy with thorough systematic checks of all staff prior to employment. Probationary period supervisions for all new staff and regular bi-monthly supervisions for all staff are now carried out. We have clear standards of conduct for all staff with a detailed disciplinary process that can be implemented if necessary; this is included in staff handbook given to all staff. There is a comprehensive training programme for all staff, and policies and procedures are available for staff to read and sign when they have done.” People using the service said, “I like living here, the staff are nice.” Four people reported that staff always listen to what they say and act upon it. Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 23 Staff told us, “I feel that the manager and deputy are very approachable and I feel confident that they listen to me.” All staff that returned surveys said that pre-employment checks are carried out, and that they receive regular supervision with the management team. Four said that the induction covered everything they needed to know but some said it partially did. We looked at 4 staff files, 3 contain two written references, two have CRB’s and the service has provided us with evidence that the CRB’s have been sent for. All staff have been checked against the PoVA, (protection of vulnerable adults) list. We looked at one application and there appeared to be a work-break that hadn’t been explained and references were from a period of employment dated from 2004 to 2006. The manager is asked to ensure that any work gaps are discussed with the employee and references sought from the last employer where possible. The organisation uses a recruitment agency for overseas workers, the copies of some of the information retained in the home are of poor quality and this included copies of photographs, application forms and ID. The service deploys a minimum of 8 staff throughout the working day; this includes two in each of the apartments plus any management hours, and maintenance hours. We saw a sample of the staff rotas and saw that while staffing levels are being maintained there is evidence some staff are working over 50 hours per week, which should be looked in to. The manager says that there are 2 full time vacancies at the moment, but the service has recently recruited two more staff for the 2 other full time vacancies. There has been a high turnover of staff at the home; information in the AQAA indicates 17 have left in the last 12 months. The manager has stated that she feels that some of the changes have benefited the service. The gender mix of staff is good as is the mix of ages. The service employs a diverse group of staff from a range of ethnic and cultural backgrounds. We understand that the employment agency carry out basic literacy checks and telephone interviews are undertaken to test language skills and levels of understanding. Records of these interviews are maintained in individual files. We have asked to be provided with up to date information about staff training but haven’t yet received this information. This means we cannot be sure that all mandatory training is up to date. The information in the AQAA shows that all staff have received training in infection control and 16 staff from the 30 employed at the service have been trained in basic food hygiene. Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 24 One survey indicated that there are never enough staff and training is not always relevant to the role, the induction only partly provided what they needed to do the job and the manager never meets to offer support and supervision. Most surveys made positive comments about their induction and training experience, and when asked what the service could do better, responses included: “The service could provide more training in autism so that new staff members can understand the needs of the service users.” “ More training on autism spectrum disorder needed.” Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 25 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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that the service is appropriately managed and that the management team know what they need to do to continually improve the service for the benefit of the people who live there. EVIDENCE: The service has told us in the AQAA that, “We provide an open and respectful management approach, with an open door philosophy. We provide a role model for high standards of care and interaction with service users. Mentoring of new staff. We set clear standards to staff and are responsible for ensuring the implementation of policies and procedures.” The manager is approved by us and registered as the manager of the service. She is a qualified Registered Nurse in Learning Disabilities (RNLD), and has Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 26 had previous experience as the manager of a registered care home. A deputy manager, who is trained to National Vocational (NVQ) Level 3, supports her. Staff have said, “The manager and deputy manager are very approachable and easy to talk to concerning work or personal issues,” and, “Supportive manager who is educated and a nurse have resulted in a rapid decrease in service users behaviour who clearly understands their needs, well being and clinical input.” In relation to quality, we saw evidence of a Quality Improvement Plan based upon the last clinical governance audit of the service. Monthly audits are also carried out and we saw the outcomes of the last medication audit. A representative of the provider visits the service monthly to report on the conduct of the service. We saw that the records of these visits are maintained in the home. The service is in the process of re-applying for Autism Accreditation with the National Autistic Society as the previous accreditation lapsed; the manager is in discussion to arrange this for January 2009. Information in the AQAA tells us that the service ensures that equipment in the home is serviced regularly; this includes the fire alarm system, gas and electrical equipment. Risk assessments are in place where needed and these are subject to regular review. The fire safety officer has told us that they are currently satisfied with the current fire safety arrangements in this home. We looked at a sample of fire safety checks and drills to confirm they are taking place regularly. Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 27 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 3 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 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 2 35 3 36 3 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 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 3 3 3 3 x Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 28 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 YA1 Good Practice Recommendations Each person using the service should have their own Service User Guide that details their terms and conditions of residency and the costs and fees they pay. The service needs to ensure that people using the service are provided with a range of activities in the home as well as when they are out. The service should look into arranging holiday’s or short day trips for the people using the service. The stained carpet in apartment 2 should be deep cleaned. The service should ensure that evidence of all recruitment checks are maintained in the home. The service should ensure that where employment gaps are noted there is evidence of discussion and explanation DS0000008324.V370539.R01.S.doc Version 5.2 Page 29 2. YA14 3. 4. 5. 6. YA14 YA24 YA34 YA34 Collinson Court 7. 8. YA20 YA32 of this. The service should ensure that where ‘as required’ medication is prescribed the instructions for administration are compatible with those in the protocol. The service should ensure that records are available to show that all staff have received mandatory training. Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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. Extracts may not be used or reproduced without the express permission of CSCI Collinson Court DS0000008324.V370539.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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