Care Home: Ferncliffe Road

Similar services:

• Larch Avenue
• Alderson Road 12
• Cranworth Close Registered Care Home
• The Cornerstone
• John Street Nursing Home
• Pennine Camphill
• Whitwood Hall
• Muston Road (70)

What the care home does well What has improved since the last inspection? People who live at the home receive better quality meals that are more varied and more nutritious. The home has a new bath and this has improved the quality of personal care. Equipment is stored properly and people have lockable cabinets so their personal items can be locked in their room. The management of the home is generally more organised and staff are clearer about their roles and responsibilities. What the care home could do better: Some aspects of the care planning process should be more thorough to make sure people`s needs are properly met. All keyworker reviews should identify what people have done and what they would like to do in the future to make sure care plans and goals are being achieved. Staffing levels should be increased on an evening and weekend to make sure people get more opportunities to go out and have more quality time with staff. A relative survey said they thought staff were `stretched`. The costing of the transport must be monitored more carefully to make sure people are not paying too much money. More information should be recorded about how people`s personal care needs have been met to make sure staff know when people have had a bath or shower. The kitchen needs replacing because the units are damaged and they cannot be cleaned properly. Staff training records should be updated because it is not possible to see if everyone`s training needs had been met. It was unclear when staff last did fire training.The home is well managed but the absence of a registered manager leaves the service vulnerable. This puts people at risk as there is no-one accountable for managing the service on a day to day basis. CIC should do more quality monitoring to make sure the home is providing a good service. Eight requirements and two recommendations were made and are at the end of this report. CARE HOME ADULTS 18-65 Ferncliffe Road 19 Ferncliffe Road Leeds West Yorkshire LS13 3PH Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 12th December 2007 09:45 Ferncliffe Road DS0000001450.V355560.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 Ferncliffe Road DS0000001450.V355560.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. Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ferncliffe Road Address 19 Ferncliffe Road Leeds West Yorkshire LS13 3PH 0113 2557443 F/P 0113 2557443 fernclifferoad@c-i-c.co.uk www.c-i-c.co.uk. Community Integrated Care 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) vacant post Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2007 Brief Description of the Service: Ferncliffe Road is a single-storey purpose built home situated in Bramley. It has a large enclosed garden to the rear of the building. A car parking area is located at the front of the building. Local shops and Bramley town centre are within easy access. Ferncliffe Road is part of the Community Integrated Care (CIC) organisation, and is registered to provide personal care for up to 4 people with learning disabilities. The accommodation consists of four single bedrooms, a lounge and separate dining room, shower room and bathroom, laundry, and a domestic style kitchen. The fees charged by the home is £947.17. This information was provided on 12 December 2007, during the inspection. Information about the home including a Statement of Purpose, Service User Guide and previous inspection reports are available at the home. Up to date information about fees can be obtained directly from the home. Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care (CSCI) inspects care homes to make sure the home is operating for the benefit and well being of the people who live there. More information about the inspection process can be found on our website www.csci.org.uk The last key inspection was carried out in January 2007. Before this unannounced inspection visit on the 12 December 2007 evidence about the home was reviewed. The manager completed an annual quality assurance assessment (AQAA) and we used this to help us decide what we should do during our inspection. Surveys were sent out to relatives of the people who live at the home and health and social care professionals. Surveys were not sent to the people who live at the home because it was agreed that they would not understand the surveys. Three surveys were returned. One survey was from a relative and two were from professionals. Comments from the surveys have been included in the report. The visit was carried out by one inspector over two days. On the first day of the inspection, everyone was going out for a Christmas lunch. The first day the inspector was there between 9.45am and 12.30pm, and the second day between 1.30pm and 3.30pm. During the inspection, time was spent looking around the home and talking to people who live and work there. This included three staff and the manager. People who live at the home have complex needs and discussions with them were only very brief. Interactions between staff and the people who live at the home were observed. Care plans, risk assessments, healthcare records, meeting minutes, and staff recruitment and training records were looked at. Feedback was given to the manager at the end of the visit. What the service does well: People who live at the home receive a very individualised service and their care is tailored to meet their individual needs. They do different activities and have different levels of support depending on their needs and wishes. A relative survey confirmed they were happy the manager and staff. It said ‘very good with the personal touch’ and ‘gets nice staff’. Staff have worked at the home for a long time and know the people well. Professionals who have been involved in the service were very complimentary, they said: Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 6 • • • ‘This service has a very person centred approach’ ‘I was very impressed regarding the commitment this group of staff demonstrated’ ‘The current manager and staff are very caring towards the clients’ What has improved since the last inspection? What they could do better: Some aspects of the care planning process should be more thorough to make sure people’s needs are properly met. All keyworker reviews should identify what people have done and what they would like to do in the future to make sure care plans and goals are being achieved. Staffing levels should be increased on an evening and weekend to make sure people get more opportunities to go out and have more quality time with staff. A relative survey said they thought staff were ‘stretched’. The costing of the transport must be monitored more carefully to make sure people are not paying too much money. More information should be recorded about how people’s personal care needs have been met to make sure staff know when people have had a bath or shower. The kitchen needs replacing because the units are damaged and they cannot be cleaned properly. Staff training records should be updated because it is not possible to see if everyone’s training needs had been met. It was unclear when staff last did fire training. Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 7 The home is well managed but the absence of a registered manager leaves the service vulnerable. This puts people at risk as there is no-one accountable for managing the service on a day to day basis. CIC should do more quality monitoring to make sure the home is providing a good service. Eight requirements and two recommendations were made and are at the end of this report. 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. Ferncliffe Road DS0000001450.V355560.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 Ferncliffe Road DS0000001450.V355560.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): 2 People who use the service experience good quality outcomes in this area. People’s needs are properly assessed before they move into the home so everyone can be sure that the person is moving into the right home and their needs can be met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The last person to move into the home did so in 2003, therefore there was very little recent evidence available for many aspects of this outcome group. The admission process was looked at during previous inspections and the relevant National Minimum Standards were met. At the time of the inspection, the home had a vacancy and a person was ‘test driving the home’ to find out if it was suitable and could meet their needs. They had visited the home several times, and the management team from Ferncliffe Road and other professionals were completing assessments. The manager was talking to an occupational therapist about suitable equipment at the time of the inspection. In the AQAA, under the ‘what we do well’ section, the manager said, ‘provide Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 10 prospective service users with information they require to make informed choice about where to live; assess prospective service users individual needs and aspirations; demonstrate to service users that the home they choose will meet their needs and aspirations; offer prospective service users the opportuninty to try the home’. Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use the service experience good quality outcomes in this area. People receive a good and very individualised service and their care is tailored to meet their individual needs. Some aspects of the care planning process has not been done properly and this could lead to some people’s needs not being met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: In the AQAA, under the how we have improved in the last twelve months the manager said they have, ‘regular keyworker meetings, regular house meetings including service users’, and ‘involved service users in the selection process of potential staff members’. Staff said people at the home had very different needs. For example one person likes to go out as much as possible, another person likes some quiet Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 12 time on their own. Staff said they thought the home was good at providing very individual care and meeting people’s different needs. Staff talked about keyworkers and their responsibilities. Each person at the home has up to three keyworkers. They said the staff team and people at the home are involved in deciding who would be the ‘best keyworker’ for the person. Staff said keyworker meetings were held monthly although the most recent keyworker meeting minutes were only available for September and December. One staff explained the process and said they sit down as a team and look at what the person should do over the next month. This includes social outings and healthcare appointments. They also review what they did the previous month. Staff said the keyworker meetings were good because they monitor what people have done and make sure set targets are achieved. Two sets of keyworker meetings were looked at and these were very different. One set of minutes identified what the person had done the previous month and what they should do the following month. The other set of minutes was general and didn’t identify what the person had done or suggest future activities. Two plans were looked at. They had some good information about the person and provided guidance on how their needs should be met. For example one plan stated the person ‘will give you her cup to refill or put it in the sink’ if she doesn’t want another drink. The person was seen to do this several times during the inspection. A large section of one plan had recently been re-written. This had very good detail, and observation and discussions with staff confirmed that the care plan accurately reflected the person’s needs. One person who has some very specialised needs had very detailed care plans that had been completed with help from other professionals. This is good practice and demonstrates that staff and management seek guidance from the right people. The care plans did have gaps and there is still some work to do before the care plans will provide a full picture of the type of care each person should receive. For example under ‘exercise’ one stated ‘doesn’t do the above’ but staff had talked about regular physiotherapy, under ‘use of shops’ it stated ‘goes to shops with carers’. Further gaps relate to personal care needs and are discussed in more detail later in this report. Some of the plans were not dated or signed so it was difficult to establish if the information was current or who had been involved in writing and agreeing the plans. Ferncliffe Road DS0000001450.V355560.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): 12, 13, 15, 16 & 17 People who use the service experience good quality outcomes in this area. Everyone has a different lifestyle, which is based on their needs and preferences, although this could be improved if there were more opportunities to go out on an evening and weekend. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: One relative survey was returned. It was positive about the approach and attitude of the staff and the manager. For example it said ‘very good with the personal touch’ and ‘gets nice staff’. They also thought staff were ‘stretched’ and made the following suggestions to improve the service; higher level of staffing so people can go out more and less use of agency staff because they cannot supply the same level of continuity. Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 14 Staff gave examples of the different levels of involvement that people have with daily living tasks. One person likes to watch staff cooking, another person likes to help make their eggs and a cup of tea on a morning, another person likes clearing tables and putting their washing in the washing machine. It was evident from discussions that involvement is pitched at a level that is appropriate to each person’s wishes and abilities. The daily records for two people, covering a four-week period, were looked at. The records gave good information about the mood of the person and whether they had eaten well. For example staff had written if a person had been laughing, or chatty or if they had been quiet or restless. One person had regular trips out for lunch and shopping. The other person attended a day centre five days a week and had spent time relaxing. One evening a week an entertainer visits the home and spends time with everyone who lives there. Staff said they all enjoyed the session. Staff and management said that when only two staff were on duty, trips and quality time with people were much more difficult to arrange. Daily records supported this because there were no evening outings and generally weekend activities were at the home. One person had had a ride out to a nearby village the Sunday before the inspection. On the first day of the inspection people were going out for a Christmas lunch. Staff were supporting people to get ready and were making sure preparations were relaxed and enjoyable. Staff were seen to enthusiastically discuss the meal with one person who was looking forward to going but they also gave reassurance to another person who often gets anxious. The manager confirmed that each person makes a contribution of £16.50 per week towards the cost of the home’s vehicle. Daily records confirmed that over a period of four weeks, one person had used the vehicle several times per week, another person had only used the vehicle twice. The transport record confirmed that the vehicle was used on almost a daily basis so there was evidence it is a good resource. Transport records do not contain details of who has travelled on the vehicle so it is difficult to monitor how often people use the vehicle. Staff and the manager confirmed that the level of use is different for different people. The last inspection identified that the home must look at the cost of the vehicle to make sure it is equitable and people are getting value for money. This has not been done satisfactorily because based on the evidence in the daily records, two trips over a period of four weeks, has cost £66, which seems some what excessive. Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 15 The inspection in January 2007 identified that people were not given a healthy and nutritionally balanced diet. Since the inspection new menus have been introduced. These are much healthier, more varied and nutritious. Variations to the menu were recorded on the food record. Staff and manager said the meals were a lot better and they thought this was an area where they had made real improvement. Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience good quality outcomes in this area. The home has good systems in place to make sure healthcare needs are met. The lack of written information could lead to some personal care needs being overlooked. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: In the AQAA the manager said there is ‘flexibility in times of getting up or going to bed, mealtimes, activities’ and ‘service users are encouraged to choose their own clothes’. Daily records confirmed that people went to bed at different times and got up at different times. One person’s record regularly stated that they had got up later than usual because they were tired. Daily records also confirmed that people did not attend day care if staff thought they were tired or ill. Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 17 Some information in daily records was generalised. Staff regularly used the term ‘all cares given’. It was difficult to establish what this meant. One staff said they had given the person a bed bath’ but in the daily notes it said ‘all cares given’. From the daily records it was not possible to establish if one person had had a bath in the last four weeks. Care plans had information about personal care. One plan had very good guidance and stated the type of toiletries that should be used and the amount of support that should be provided. For example ‘explain in simple words and by doing hand over hand assistance’. Another care plan did not have enough information, for example under the bathing section it stated ‘bathed by two carers on a regular basis’. A risk assessment identified that one person was at risk from pressure sores but there was no care plan for pressure care. The manager agreed to look at the care plans and make sure they were all of a similar standard. The general appearance of people who live at the home was good, they were dressed appropriately and attention had obviously been given to their personal care. For example, people’s hair had been brushed, and shoes and clothing were clean. Staff said they were good at meeting people’s personal and health care needs. Two professionals who have had recent involvement with people who live at the home returned surveys. Their responses were positive and the following is a sample of typical comments: • • • This service has a very person centred approach I was very impressed regarding the commitment this group of staff demonstrated The current manager and staff are very caring towards the clients Each person has a health action plan that identifies their healthcare needs. There is information about the support they need during healthcare appointments and how often they should attend. Healthcare records confirmed that people were receiving healthcare services as written in their health action plan. One person’s record confirmed they had attended a dental appointment and a chiropody appointment in November and a GP appointment in December. The home’s medication system is a Monitored Dosage System. Medication records were looked at and they had been completed correctly. The manager confirmed that staff who administer medication must have completed medication training. Ferncliffe Road DS0000001450.V355560.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): 22 & 23 People who use the service experience good quality outcomes in this area. The people who live at the home are safeguarded. People are confident that they will be listened to and that appropriate action will be taken when necessary. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: In the AQAA the manager said in the last twelve months they have improved by providing accessible complaints, compliments and abuse procedures. She also said they had not received any complaints. One professional survey stated that the current manager is good at reporting concerns and responding well to them. It also stated that incidents have been investigated thoroughly and appropriate action has been taken under safeguarding procedures. Another professional survey and the relative survey stated that the care service has always responded appropriately if concerns have been raised. Staff said the manager is approachable and they would talk to her if they had any concerns. Staff and management have attended safeguarding training and were familiar with the adult protection procedures. Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 19 Personal allowance records were looked at. All financial transactions were recorded. Two people’s monies were counted and the amount corresponded with the amount on the balance sheet. Ferncliffe Road DS0000001450.V355560.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): 24 & 30 People who use the service experience good quality outcomes in this area. The home is pleasant, reasonably well maintained and people are comfortable in their surroundings. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: A tour of the building was carried out. All bedrooms, communal areas and bathrooms were visited. The home was clean and tidy and there were no odours. Decoration and furnishings were of a good standard. All communal areas had been decorated since the last inspection. The garden was well maintained and a pleasant area that people could safely use. People who live at the home walked freely around the home and used all communal areas. Bedrooms were personalised and each room had items that reflected individual preferences. This is good practice and demonstrates that everyone is encouraged to make their rooms homely. Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 21 The bathroom and two bedrooms have overhead tracking and a mobile hoist is provided for use in communal areas. There was a supply of disposable gloves, wipes, anti bacterial hand wash and paper towels throughout the home. They had appropriate laundry facilities. The last inspection identified that the kitchen units should be replaced because the edgings on several unit doors and handles were damaged and they could not be cleaned properly to prevent the spread of infection. CIC had also identified they needed replacing. This has still not been done. The manager said she has been told a new kitchen will be fitted next year. This is not satisfactory because once an organisation has identified a risk it should take action to put it right. A year is not an acceptable timescale. The last inspection identified that people couldn’t have a bath because it was broken, some prescribed items were not locked away and some equipment was being stored in a bathroom. These issues have been addressed. A new bath has been installed. Lockable cabinets have been put in each person’s room and equipment has been stored properly or returned to the supplier. Ferncliffe Road DS0000001450.V355560.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): 32, 33, 34 & 35 People who use the service experience adequate quality outcomes in this area. People who live at the home are supported by staff that know them well. Good systems are in place to make sure the staff feel supported. On occasions, staffing levels are not satisfactory and this affects the quality of the service because people cannot go out as often as they would like and quality time with staff is limited. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home has a low turnover of staff and many staff have worked at the home for a long time and they have good knowledge about the people who live there. Staff talked positively about support from management and colleagues and working as a team. Staff confirmed they spend time, on a one to one basis, Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 23 with the manager or senior talking about things that relate to the home and their personal development; this is called staff supervision. The last inspection identified that on occasions staffing levels were not satisfactory. Again at this inspection concerns were raised about staffing levels. Staffing has had an impact on the quality of people’s lifestyles. Staff and the manager said that it was difficult to organise outings and quality time with people on an evening and weekend when only two staff were on duty. In addition to the staffing levels, the home has been using a lot of agency staff. Again, staff said this has affected the quality of the service, because agency staff do not have in depth knowledge of people who live at the home and cannot take people out unsupervised. Rotas were looked at and for the majority of evenings and weekends only two staff had been on duty at any one time. No new staff have started work at the home since the last inspection. One person had transferred from another unit and they knew the people who live at the home because they worked there several years ago. In the AQAA the manager said ‘all staff new or established are given regular in house or updated CIC training to ensure they are competent and qualified in the areas they are working in, this makes an effective team for the service users’. All staff and the manager said CIC are good at providing training opportunities. They said they thought their training needs were met. Staff said the manager is good at encouraging people to attend training courses. Training records were not up to date so it was not possible to confirm that training needs were met. Fire training records could not be found so there was not enough evidence to confirm that everyone’s fire training was up to date. Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 People who use the service experience good quality outcomes in this area. The home is well managed but the absence of a registered manager leaves the service vulnerable. This puts people at risk as there is no-one accountable for managing the service on a day to day basis. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home has not had a registered manager since January 2006. A requirement was made at the last inspection that the manager must submit a registered manager’s application. The manager sent her application in October 2007 but because the criminal record check (CRB) was out of date it was Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 25 returned. The manager said she had just received a new CRB and would submit her application within two weeks. It was also identified that the manager was having difficulty in carrying out all her management duties because she was managing two homes and did not have enough management time, and support staff were making management decisions that were outside of their remit. These problems have been addressed. An additional 22 ½ senior hours have been allocated to the home and the manager has introduced a system to clarify roles and responsibilities. The staff rota clearly identifies who is the lead person on each shift. Staff said they thought the management of the home was good and they thought the home had generally improved in the last twelve months. In the AQAA the manager said she ‘has seven years experience in a significant management/supervisory role withion the care sector’. She also said ‘the resistered manager has overall responsiblilty as set out in their job description’ and ‘the registered manager undertakes regular training and development’. The statement that relates to the registered manager is incorrect because the home does not have a registered manager. All three surveys made positive comments about the manager. One described her as excellent, another said she is very good, and the other said she provides good leadership. At least once a month CIC must organise a visit to the home to make sure everything is satisfactory, these visits are called Regulation 26 visits. The area manager had visited the home and completed some of these visits but they had not been as frequent as monthly. For the last six months, reports were available for June, July and September but they were not available for August, October and November. The manager said CIC send out questionnaires to people who live at the home, relatives and staff although she acknowledged none had been sent out in the last twelve months. In the AQAA the manager said relevant policies and procedures were in place, and many were reviewed in the last two years. She also said equipment has been serviced or tested as recommended by the manufacturer or regulatory body although the premises electrical service was left blank. It was confirmed at the inspection that the electrical wiring certificate was issued in March 2007. Dates for servicing portable electrical equipment and hoisting equipment were verified at the inspection. No concerns around safe working practices were seen on the day of the inspection. Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 3 2 X X 3 X Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 27 Yes 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 Regulation 15 Requirement Service user plans must have enough detail so everyone understands how people’s needs should be met. This will make sure people are given the right support to meet their needs. This must include a plan for pressure care when it has been identified as a risk in a risk assessment. Plans must be dated and signed so everyone knows when the plan was written and who has agreed the plan of care. Transport arrangements must be fair and equitable so people are not being over charged and are getting value for money. Timescale of 31/03/07 not met Individual records must identify how personal care needs have been met to make sure people are receiving the right personal care to meet their needs. The kitchen must be in a good state of repair. This will make DS0000001450.V355560.R01.S.doc Timescale for action 29/02/08 2 YA13 17 12 16 29/02/08 3 YA18 12 31/01/08 4 YA24 23 30/04/08 Ferncliffe Road Version 5.2 Page 28 sure people are living in a home that is pleasant, clean and safe. Timescale of 31/05/07 not met There must be sufficient staff working at the home. This will make sure people’s needs are met. 5 YA33 18 31/01/08 6 YA35 7 YA37 Timescale of 31/03/07 not met 17 There must be an up to date training record to demonstrate that staff’s training needs are met. CSA The acting manager must make Section 11 an application to be registered to make sure the home has a person who is responsible for the day to day running and is accountable to the Commission. Timescale of 30/04/07 not met The quality of the home must be properly monitored to make sure the home is providing a satisfactory service. Timescale of 31/03/07 not met 31/01/08 31/01/08 8 YA39 24 31/01/08 Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA13 Good Practice Recommendations Keyworker reviews should be carried out properly to make sure care needs are properly monitored and appropriate action plans are in place. On an evening and weekend, people should be given more opportunities to go out and spend more quality time with staff. This will make sure people have a fulfilling lifestyle. Ferncliffe Road DS0000001450.V355560.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Ferncliffe Road DS0000001450.V355560.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!