Care Home: Headonhey

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What the care home does well Staff members spoken to and observed during the site visit showed a high level of commitment to supporting people to make their own choices and to be as independent as possible. They had a very detailed knowledge of people`s needs and the ways that they communicate their choices and decisions. When they were asked about the people they support they did so in a very positive and respectful way. For example, a staff member said about one person, `They are very social, really talkative, loves being around people and so veryfriendly`. They were also aware of people`s vulnerability and the risks they face and how to work with people to reduce those risks to a minimum. Staff were also very positive about the level of training and support they received from the management team and the company itself. The staff members spoken to during the site visit and the vast majority of staff who returned surveys were all very positive about the Induction and training they received and said that they had regular meetings and supervision with the management team. One staff member felt that the service provided, `high standards of care, good team work, good training service, they are always looking for ways to improve`. The support that people received from the staff and management team was viewed as very positive by people`s relatives. A lot of effort from the team went into supporting people to maintain good relationships with their families, where possible. As one relative commented, `The staff treat each resident as an individual and tailor their care to the needs, choices etc of each. A high quality of life is provided for all and staff are friendly and helpful. It appears that nothing is too much trouble, when staff frequently "go the extra miles" to ensure that residents are happy and well cared for. The management and staff team support people with a range of health needs that can be complex and require a lot of staff support and monitoring. People`s health needs have been clearly identified and the management team have put in place very detailed and person centred information (often using appropriate pictures) and guidance for the staff team explaining how people`s health was to be supported and maintained. The staff members spoken to during the site visit had a very good knowledge of people`s health needs and of the specific healthcare support. The staff and management team devote a lot of their time and resources to supporting people to have the opportunities to participate in varied and meaningful activities both within the home and in the community. Staff members were able to describe what social activities people liked and disliked and where possible people were supported to access a menu of activities based on what they liked to do. The staff and management team stressed the importance of choice and being able to support people to communicate their choices and this was emphasised through a comment made by a family member who stated that, `my daughter is always given choices about all aspects of her life re clothes, activities, meals, trips and shopping. She goes where she wants to`.HeadonheyDS0000005612.V365913.R01.S.docVersion 5.2Page 7 What has improved since the last inspection? There were no requirements made at the previous key inspection. What the care home could do better: There is a policy and set of procedures in place for staff to follow when supporting people with their personal monies and spending. Staff must make sure that they follow these procedures for the protection of people and themselves. CARE HOME ADULTS 18-65 Headonhey 34 Harboro Road Sale Manchester M33 5AH Lead Inspector Steve O’Connor Unannounced Inspection 18thJune 2008 10:00a Headonhey DS0000005612.V365913.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 Headonhey DS0000005612.V365913.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. Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Headonhey Address 34 Harboro Road Sale Manchester M33 5AH 0161 969 3527 0161 976 3617 enquiries@stockdales.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Stockdales of Sale, Altrincham & District Ltd Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users have a learning disability and may have an associated physical disability. 21st July 2006 Date of last inspection Brief Description of the Service: Headonhey is a care home providing personal care and accommodation for 7 young adults with complex needs (registered for learning disabilities and associated physical disabilities). It is managed and owned by Stockdale’s of Sale, Altrincham and District Limited (Stockdales), which is a charitable organisation. The home is located in an established residential area in Sale, close to shops, bus and train routes and other amenities. The home was opened in 1992 and consists of a two-story building. The communal areas are located on the ground floor, including a lounge, kitchen and dining area. All bedrooms are single and situated on the first floor with a passenger lift provided for access. Bathroom and shower facilities are provided on both the ground and first floor. The home has a drive and patio area to the front of the property and a paved patio area to the rear. All outdoor areas were accessible for wheelchair users. The weekly fees charged at time of this inspection ranged between £1019 and £1438. The home’s inspection reports are made available to residents’, families and professional on request. A copy of the home’s Statement of Purpose and Service User’s Guide is always made available to read at the home. Headonhey DS0000005612.V365913.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 3 star. This means the people who use this service experience excellent quality outcomes. The inspection report is based on information and evidence we (the commission) gathered since the last key inspection in July 2006. Additional information, which has been taken into account, included an Annual Service Review (ASR) report that we completed in February 2008, incidents notified to us and information provided by other agencies. Before visiting the home, we asked the manager to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This helped us to determine if the management of the home viewed the service they provide the same way that we see the service. Before visiting the home people who used the service, their relatives and members of staff were sent surveys and asked to comment on the care home. By the time of the visit four relatives and 8 members of staff had returned surveys. Surveys had been returned on behalf of the seven people living at the home but had been completed by members of staff. During the inspection site visit time was spent talking to the management and staff team. The people who were in during the inspection site visit communicated mostly through body language, signs and sounds and so it was not possible for us to ask direct questions. Documents and files relating to people and how the home was run were also seen. The inspection was an opportunity to look at all the core standards of the National Minimum Standards (NMS) and was used to make a judgement on the quality of the service provided by the home and to decide how much work we need to do with them in the future. What the service does well: Staff members spoken to and observed during the site visit showed a high level of commitment to supporting people to make their own choices and to be as independent as possible. They had a very detailed knowledge of people’s needs and the ways that they communicate their choices and decisions. When they were asked about the people they support they did so in a very positive and respectful way. For example, a staff member said about one person, ‘They are very social, really talkative, loves being around people and so very Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 6 friendly’. They were also aware of people’s vulnerability and the risks they face and how to work with people to reduce those risks to a minimum. Staff were also very positive about the level of training and support they received from the management team and the company itself. The staff members spoken to during the site visit and the vast majority of staff who returned surveys were all very positive about the Induction and training they received and said that they had regular meetings and supervision with the management team. One staff member felt that the service provided, ‘high standards of care, good team work, good training service, they are always looking for ways to improve’. The support that people received from the staff and management team was viewed as very positive by people’s relatives. A lot of effort from the team went into supporting people to maintain good relationships with their families, where possible. As one relative commented, ‘The staff treat each resident as an individual and tailor their care to the needs, choices etc of each. A high quality of life is provided for all and staff are friendly and helpful. It appears that nothing is too much trouble, when staff frequently “go the extra miles” to ensure that residents are happy and well cared for. The management and staff team support people with a range of health needs that can be complex and require a lot of staff support and monitoring. People’s health needs have been clearly identified and the management team have put in place very detailed and person centred information (often using appropriate pictures) and guidance for the staff team explaining how people’s health was to be supported and maintained. The staff members spoken to during the site visit had a very good knowledge of people’s health needs and of the specific healthcare support. The staff and management team devote a lot of their time and resources to supporting people to have the opportunities to participate in varied and meaningful activities both within the home and in the community. Staff members were able to describe what social activities people liked and disliked and where possible people were supported to access a menu of activities based on what they liked to do. The staff and management team stressed the importance of choice and being able to support people to communicate their choices and this was emphasised through a comment made by a family member who stated that, ‘my daughter is always given choices about all aspects of her life re clothes, activities, meals, trips and shopping. She goes where she wants to’. Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? 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. Headonhey DS0000005612.V365913.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 Headonhey DS0000005612.V365913.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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People’s needs were being regularly reviewed and re-assessed through formal review processes. EVIDENCE: The people who live at Headonhey have done so for many years and most came to live there through Stockdale’s own care home for children. A sample of a Care Management review report was seen from a purchasing local authority where a person’s needs were reviewed and reassessed to make sure that they were being met. In addition, people were supported to hold their own reviews on an annual basis where relatives, staff members and other relevant professionals were invited to attend to review people’s progress and achievements. Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 10 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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems were in place to assess and reflect changes in peoples’ support needs, the risk situations they experience and they were supported to make decisions about their own lives. EVIDENCE: The majority of people expressed themselves and made choices and decisions through their body language, sounds and words. A recent review of a person’s goals and support highlighted the importance of communication in making choices such as in activities, meals, what they want to watch on television or music to play. The review gave some information about the person’s communication skills and staff members spoken to during the site visit were able to describe and explain how the person communicates their needs and preferences. Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 11 Some examples of work carried out with people and staff members were seen in the form of ‘Communication Passports’. These booklets provided a wealth of information about how a person communicates their likes and dislikes and how they make decisions. This guide gave staff clear guidance on how to support that person to make day-to-day choices about their life. It was found that only three of the seven people who live at the home had a communication passport and people’s communication needs were not fully reflected within their care plans. It is recommended that everyone is supported to develop their own personal communication passport that gives staff the guidance and information they need to be able to offer people meaningful choices and decision making. Samples of people’s care plans were seen and these were generally detailed and included people’s needs in relation to their personal and healthcare. A number of people had a range of complex health needs and this was reflected in very detailed care plans and guidance for staff to follow. Care plans also highlighted goals in other areas of people’s lives such as social and leisure, cultural and relationships. The information was clear and reflected people’s needs. A sample of a care plan review, undertaken by the staff team, was seen and found that the issues discussed at the review and the actions agreed had been recorded with a person centred approach. The information related directly to the person, their strengths and skills and how they have achieved their goals. The meeting included the person and people who were important to them. It was found that there was more person centred information and more indepth quality information within the review compared to the care plan record. It is recommended that the management and staff team work with people to develop even further the person centred approach to the care planning documentation. Samples of risk assessments were seen that looked at hazards and situations that could cause a person harm. Many of the risk assessments seen related to people’s health and the tasks needed to keep people well and safe. Other risk assessments seen related to supporting people in the community and transport. Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 12 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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were being supported and encouraged to participate in activities and establish routines that they valued and enjoyed. People’s families were involved in their lives where this was wanted and they were able to choose meals they enjoyed. EVIDENCE: People’s care plans and records contained information about the activities that they enjoyed and liked to participate in. The staff and management team had developed an understanding of what activities and routines people enjoyed and supported people to take part. People were supported to go to a college offering specialist courses and everyone had the opportunity of taking part in the ‘social therapy’ service that Stockdale’s offers all the people they support. Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 13 In addition to this people were supported to access community social and leisure activities based on a menu of activities that they enjoy. This could include trips to local attractions, meals out, visits to local pubs and shopping facilities. The home provided people with a weeks holiday where they were supported by staff. Last summer several people went to Euro Disney and another trip was being planned for this summer. People were also supported to take part in activities at home with a variety of games and action activities. Records were being maintained of all the activities that people participated in. People were supported to develop their own personal routines based on choice. The staff members spoken to during the site visit had a very good understanding of what people enjoyed and how they communicated choice in terms of activities and other areas such as meals. Where possible people’s families are encouraged and supported to take an active role in their lives. Family members were encouraged to visit and to take part in activities with people. They were invited to reviews and meetings and involved in gathering information about the quality of the service people receive through the quality assurance programme. During the site visit some people took a break from the social therapy activities to have lunch. This was a relaxed and informal affair with staff interacting with people and preparing the meal. Meals were cooked in a kitchen connected to the home. The chef on duty was able to describe who required thickened meals and people’s nutritional needs. They stated that they knew people for a long time and so had not recorded any of this information. It is recommended that a record of people’s nutritional needs and preferences was available to all staff who work in the kitchen preparing meals. Meals and menus were developed through consultation between people, the chef and staff members. The chef had a system for gaining written feedback on the quality of meals. At the time of the site visit this was not being completed by Headonhey. It is recommended that the system for recording the quality monitoring of meals be undertaken by the staff team. Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 14 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 excellent. This judgement has been made using available evidence including a visit to this service. People’s personal and healthcare needs were being supported by the staff team to make sure that they remain well. EVIDENCE: Several people had very complex health needs that required specific support and the use of equipment. The care planning system provided a great deal of information and guidance setting out how staff were to support these health needs to keep people well. Staff members spoken to during the site visit were able to describe people’s health needs and the training they had undertaken to meet specific needs such as jejunostomy care and suctioning. The input from other health providers had been fully recorded and several people had a multi-disciplinary team of health providers working together to meet their needs. This information was brought together in people’s individual Health Action Plans. Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 15 Personal care guidance in relation to oral hygiene, continence and moving and handling were available to give staff instructions in how to support people’s needs. However, from talking to staff on duty, they were able to describe in much greater detail how a person likes to be supported in their personal care and how they are offered choices and how things were explained to them whilst providing the care. Very little of this person centred information was recorded through the care planning process. It is recommended that people’s care plans fully reflect their own personal care needs and support in a person centred way that explains to staff what was important for the person. The medication administration system was assessed and found that the medication administration records (MAR) sheets had been completed accurately with staff signatures and clear records of when it was not possible to administer. Some people were prescribed with medication ‘as required’ (PRN) and clear administering and guidance instructions had been developed for staff to follow. Several people had an epilepsy plan that involved the use of rectal diazepam. There were clear records for administering the medication and evidence that staff had received training in its use. Before staff are allowed to administer medication they must attend the relevant training course and be assessed as competent. This process involved being observed and questioned on at least three occasions by a senior member of the staff team. Records of these assessments were sampled. Some people are prescribed a drink thickener. This was being recorded on the MAR sheet but not at the actual times when it was used. It is recommended that a record be maintained for each time that a prescribed thickener was used. Changes in legislation relating to controlled drugs means that the home has to provide suitable storage. It is recommended that the management seek advice from the local Primary Care Trust or their pharmacist on installing the required controlled drugs storage equipment. Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 16 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. The home has the policies and procedures in place and the staff were aware of the practices to respond to people’s concerns and to protect them from harm. EVIDENCE: A complaint policy and procedure set out the stages and timescales for making a complaint. Information had been provided to people and families in different formats to help them understand the process. Several people would have to rely on relatives or other people to be able to make a complaint and the surveys sent to relatives showed that they all knew how to raise concerns with the management team. Information about concerns or complaints made were being maintained. They set out the concern, the actions taken and the outcome of the complaint. The information sent to us in the AQAA self-assessment stated that one formal complaint had been made in the last 12 months and that this had been resolved. It was noted that the concerns were being recorded in one book. It is recommended that incidents of complaints and concerns were recorded separately to make sure that the information recorded does not breach the Data Protection legislation. Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 17 The management and staff team followed Stockdale’s own adult protection policy and procedure as well as having access to the local multi-agency procedures for referring safeguarding issues. Records showed that most staff members had attended Protection of Vulnerable Adult training and those staff and the management team spoken to during the site visit were able to describe the actions they would take in the event of an incident. Staff were also aware of the ‘Whistleblowing’ procedures for when they have concerns about other members of staff or management. Staff could use pictorial body maps to evidence bruises and signs of injury at times when they have concerns. An example of a body map was seen and found that the record was insufficient with no detail or description of the injuries/bruising. The procedure stated that a report was to be completed in relation to the injuries found. There was no separate record of this incident. Staff spoken to during the site visit stated that they had not received any training on the use of body maps. It is recommended that staff have the skills and knowledge to complete body maps fully and accurately and follow the procedures for report writing. The finance systems for people’s personal monies was checked and found that the record of transactions was accurate and cash balances were being checked on a regular basis. It was found that staff were not always following the procedures for purchasing drinks/food when supporting people in the community. This issue was raised with the manager and a requirement was made. The manager stated that an administrator with Stockdale’s was the appointee for most of the people living at Headonhey. It is recommended that Stockdale’s consider whether an external appointee (such as the local authority) would be more appropriate in terms of safeguarding and the potential for a conflict of interests. Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People live in a homely and well maintained environment that meets their needs and is safe. EVIDENCE: The home was clean and well maintained and decorated in a contemporary style to a good standard. The ground floor layout was open-plan with a large lounge and dining area. The space was flexible and sufficient to allow people freedom of movement. The lounge area contained a tracking hoist to further aid people’s mobility needs. A changing room facility was sited on the ground floor. Bedrooms are accessed via a passenger lift to the 1st floor. All the bedrooms seen had been individually decorated to suit people’s taste. Where possible people had chosen the style and colours used in the decoration of the bedroom. These were very personalised with items and personal affects that Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 19 reflected the person’s personality and interests. Tracking hoists were also placed in each bedroom and bathrooms. The outside space available for people to use was compact but well constructed, accessible and secure. Staff spoken to during the site visit were aware of the importance of infection control and the measures to take to reduce cross infection. Equipment to minimise cross infection was available and staff were seen wearing the required protection of gloves and aprons. Laundry facilities were sufficient to cope with the level of changes and had the right programmes to reduce risk of infection. Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 20 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 and 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People were being supported by an effective and established staff team who had the skills and knowledge to meet their needs. EVIDENCE: At the time of the site visit the staff rota showed that the team consisted of the manager, assistant manager, five full-time keyworkers (senior support workers), one staff member training to be a keyworker and a number of staff who work various hours during the day and night and were either permanently based at Headonhey or worked as a bank worker for Stockdale’s. The staff rota showed that during the day (8am to 10pm) there would be at least 4 members of staff on duty in addition to either the manager or assistant manager. The rotas showed that on certain days more staff were working to be able to support people to go to a local college. The management team and staff members confirmed that at rare times there would be three staff on duty but normally the existing team would pick up Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 21 extra shifts or the staff who work at other Stockdale’s services would cover shifts to make sure that four staff were on duty. The staff rota showed that occasionally agency staff had to be used to make sure that the staffing levels are maintained. It is recommended that Stockdale’s have written confirmation from the agency that the staff they supply have the required recruitment checks, skills and knowledge required to work with people safely. Three staff were asked about their role and how they work with people during the site visit. All the staff were very positive in the way that they described people and how they described their roles and responsibilities. They all expressed a set of values based on giving people opportunities and choices and to support people to be as independent as possible. During the site visit the interaction between people and staff was seen to be very positive in terms of the way staff spoke to people and involved them in activities and personal support. According to the information provided by the home through the AQAA selfassessment over 50 of the staff team had achieved a NVQ Level 2 or above. Staff files were sampled and found that they all contained the required documentation and recruitment checks such as references, POVA First and Criminal Record Bureau certificates. The management team carried out the interview process and records of interviews were kept. Part of the recruitment process was prospective staff spending a shift at Headonhey to meet people, the staff team and to get a direct view of the role and responsibilities of the job. The management/keyworker would assess how the prospective staff member works with people and whether they would be suitable for the post. This was seen as an example of good practice and was commended. Stockdales have a training programme for its staff in all services it provides. They provide both in-house training and access other training providers including the local authority’s own training consortium. They had recently appointed a new training manager who was in the process of developing a training matrix that would highlight whom and when mandatory and other refresher training was required. It would also log the training that staff had undertaken. The training records and discussions with staff during the site visit found that a range of training events had been provided. This included an Induction programme based on the national Skills for Care Induction modules. Feedback from the staff surveys highlighted that most staff members felt that their Induction and training programme gave them the skills they needed. Talking to staff on duty they confirmed that they had attended training events such as POVA, First Aid, medication, epilepsy, moving and handling, equality and diversity and food hygiene. Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 22 Supervision and appraisal records confirmed that training issues and needs were discussed with staff. Headonhey DS0000005612.V365913.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management team and operational systems were in place to seek peoples’ views of the service and to maintain their health and safety. EVIDENCE: The management team of Headonhey consisted of the manager and assistant manager. They usually work on opposite shifts to provide management cover across the whole day and week. In addition, there is an on-call system where managers and senior staff from across Stockdales provide support where needed. Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 24 The current manager had been in post since the 30th April 2008. They had previously been employed by Stockdale’s as a Care Manager for the whole organisation. As such they were already aware of the needs of people living at Headonhey and the staff team. The manager had several years previous management experience in a service for vulnerable people with a range of needs. They were currently undertaking the Registered Managers Award. At the time of the site visit they had not yet submitted an application to become the registered manager. The manager must submit an application for them to become the registered manager as soon as possible. Stockdales have a Quality Assurance programme that is used across its services. For Headonhey an event was organised that involved people their families and staff meeting to look at how well the service does. In addition, questionnaires were used to gather information and the views of people about the service. As a result of this meeting a report is developed that looks at issues such as relationships, choice, community presence, dignity and competence. From this process an Annual Development Plan is developed that sets out actions to be completed that will improve the service that people receive, staffing and the environment. In addition to the Quality Assurance programme regulation 26 inspections were undertaken by senior managers to look at issues of quality and the environment. Based on the information provided to us by the home through the AQAA selfassessment health and safety checks in relation to fire are made, services are checked annually and equipment is being serviced at regular intervals. Health and safety policy’s and procedures were in place. Headonhey DS0000005612.V365913.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 X 2 2 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 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 4 35 4 36 X 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 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 3 X 4 X X 3 X Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 26 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 YA23 Regulation 13(6) Requirement To make sure that people’s personal finances are fully protected staff must follow the agreed procedures for purchasing drinks/food when supporting people in the community. The manager must submit an application for them to become the registered manager as soon as possible. Timescale for action 30/08/08 2 YA37 9 30/08/08 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 YA7 Good Practice Recommendations It is recommended that the management and staff team work with people to develop further the person centred approach to the care planning documentation. It is recommended that everyone is supported to develop their own personal communication passport that gives staff the guidance and information they needs to be able to DS0000005612.V365913.R01.S.doc Version 5.2 Page 27 Headonhey 3 YA17 offer people meaningful choices and decision making. It is recommended that a record of people’s nutritional needs and preferences was available to all staff who work in the kitchen preparing meals. It is recommended that the system for recording the quality monitoring of meals be undertaken by the staff team. It is recommended that people’s care plans fully reflect their own personal care needs and support in a person centred way that explains to staff what was important for the person. It is recommended that a record be maintained for each time that a prescribed thickener was used. It is recommended that the management seek advice from the local Primary Care Trust or their pharmacist on installing the required controlled drugs storage equipment. 4 YA18 5 YA20 6 YA22 It is recommended that incidents of complaints and concerns were recorded separately to make sure that the information recorded does not breach the Data protection legislation. It is recommended that staff have the skills and knowledge to complete body maps fully and accurately and follow the procedures for report writing. It is recommended that Stockdales consider whether an external appointee (such as the local authority) would be more appropriate in terms of safeguarding and the potential for a conflict of interests. 7 YA23 8 YA33 It is recommended that Stockdales have written confirmation from the agency that the staff they supply have the required recruitment checks, skills and knowledge required to work with people safely. Headonhey DS0000005612.V365913.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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