Care Home: Shapland Close

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What the care home does well People were supported to maintain important relationships. People`s family members were recognised as strong advocates. People have had a high level of intervention from health professionals. People`s bedrooms were personalised and reflected their interests and personalities. The recruitment procedure ensured that all prospective staff members were suitable to work with vulnerable people. What has improved since the last inspection? The Statement of Purpose had been reviewed and up dated. A new care planning format had been developed yet had not been fully introduced. The detail in some care plans had been improved upon. Risk assessments were in place to address people`s risk of developing a pressure sore yet staff training in this area would enhance the assessments further. Epilepsy management profiles were in place yet not all were fully completed, signed or easily accessible to staff. The profiles did not form an integral part of the person`s care plan. One kitchen had been totally refurbished. The lounge and entrance area of both bungalows and the laundry room had been redecorated. The standard of cleanliness within the home had been improved upon. Progress had been made in relation to ensuring people received home cooked food rather than a high reliance on processed and packaged items. A range of staff training had been arranged so the majority of staff were up to date with their mandatory training. A review of staff member`s knowledge and skills had been undertaken with some matters addressed through the organisation`s employment procedures. New staff were in the process of being recruited. There was less reliance on agency staff. Staff training in manual handling had been provided by an external specialist provider and had not been cascaded down through the staff team. Interactions between staff and people using the service had been improved upon. A quality assurance system had been developed and was being implemented. What the care home could do better: Due to a high level of staff change and commitment to two services, the management team was not established or consistent. This had an impact upon the continuation of leadership within the service. Reducing staffing levels during the day and at night had potentially placed people at risk of not having their needs met. The on call system was inadequate to support the service effectively on a long term basis. While staff training had been improved upon, some staff members had not participated in all courses. Due to the complexity of people`s needs and the fact that some of these staff were lone working, the lack of their up to date knowledge, potentially placed people at risk of harm. The staffing roster must be an accurate reflection of the actual staff on duty. The times worked by the management team should be clearly stated. While a new care planning system was being introduced, the information currently available to staff did not fully inform them of people`s complex needs. This particularly applied to people`s health care needs such as epilepsy. Protocols were required for aspects of people`s care such as the administration of epilepsy `emergency rescue` medicines. Care procedures such as those to minimise soreness must be undertaken as required. Staff must not administer suppositories or any other invasive procedures unless they have been specifically trained and have had their competency assessed by a qualified health care professional. Care charts, such as those which demonstrate people`s seizure activity and fluid intake must be ordered, fully completed and regularly evaluated. While there was less reliance on agency staff, the agency staff`s suitability to work with vulnerable people should be evidenced. There should be written evidence of each staff member`s induction (including agency staff) which has been fully completed and `signed off.` Staff must receive regular fire instruction so that they are fully aware of the procedures to follow in the event of a fire. Key inspection report Care homes for adults (18-65 years) Name: Address: Shapland Close Wilton Road Salisbury Wiltshire SP2 7EJ     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Alison Duffy     Date: 3 0 0 3 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Adults (18-65 years) Page 2 of 50 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 50 Information about the care home Name of care home: Address: Shapland Close Wilton Road Salisbury Wiltshire SP2 7EJ 01722419777 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): www.scope.org.uk SCOPE Name of registered manager (if applicable) Type of registration: Number of places registered: care home 8 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 physical disability Additional conditions: The maximum number of service users who may be accommodated is 8 The registered person may provide the following category of service: Care Home only Code PC to service users of either gender whose primary needs on admission to the home are within the following category: Physical Disabiliy (Code PD) Date of last inspection Brief description of the care home Shapland Close is a residential care home registered to care for eight adults with a physical disability. The home is situated on the outskirts of Salisbury, within close proximity to local amenities. The home is managed by SCOPE. The service currently has a vacancy for registered manager. The interim manager is Mr Paul Glover. Shapland Close consists of two purpose built bungalows with disabled access throughout. Each bungalow has four single bedrooms, a spacious lounge with dining area and an adjoining kitchen and specialised bathing facilities. A range of individualised, specialised equipment is in place. An additional bungalow contains the Care Homes for Adults (18-65 years) Page 4 of 50 Over 65 0 8 Brief description of the care home office. Staffing levels are generally maintained at four or five staff on duty during the day. At night there is one waking night staff member in each bungalow. There is an on call management system in place. Care Homes for Adults (18-65 years) Page 5 of 50 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The last inspection of the service took place on the 6th and 14th October 2009. At this time, we judged the quality rating of the service to be poor. Inadequate management systems were in place which compromised peoples safety. Care planning and risk management were of a poor standard and there was inconsistency within the staff team due to a high reliance on agency staff. Staff training and supervision were limited and did not enable staff to have the right skills and knowledge to support people effectively and safely. There had been a high number of safeguarding referrals which had led to internal investigations. As we judged the outcomes for people using the service to be poor, the service received support and monitoring from Wiltshire Councils Quality Team. SCOPE also seconded a consultant to investigate service provision and to identify any shortfalls in practice. We met with the consultant in December 2009 to discuss the issues identified and how these were to be resolved. This inspection took place to ensure that the Care Homes for Adults (18-65 years) Page 6 of 50 service had focused upon the shortfalls we had identified and that they had complied with the twenty two requirements we made at our last visit. The visit took place on the 29th March 2010 between 9.20am and 4.50pm and was concluded on the 30th March 2010 between 10.15am and 3pm. Two inspectors undertook the inspection. On arrival at the service on the first day, a team coordinator was on duty with four support workers. Mr Paul Glover, interim manager was at a managers meeting in London. The team coordinator contacted Mr Glover, who then left the meeting and arrived at the service, later in the morning. Mrs Carrie Irvine, a registered manager seconded to support the management team with improving the service, also arrived at the service. Mr Glover and Mrs Irvine were both present throughout the rest of our visit and received feedback at the end. Before visiting the service, we sent the interim manager an Annual Quality Assurance Assessment (known as the AQAA.) This was the services own assessment of how they were performing. It told us about what had happened during the last year and about their plans for the future. We also took into account the improvement plan, which was sent to us following the last inspection. This showed that the shortfalls we previously identified had been addressed or were in the process of being addressed. We sent the service surveys, for people to complete if they wanted to. We also sent surveys to be distributed to members of staff and health/social care professionals. We sent one survey to a persons relative. This enabled us to get peoples views about their experiences of the service. We received one survey from a person using the service, one relative and three staff members. All key standards were assessed on this inspection. Observation, discussions and viewing of documentation gave evidence, which showed whether each standard had been met. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the experiences of people using the service. Care Homes for Adults (18-65 years) Page 7 of 50 What the care home does well: What has improved since the last inspection? What they could do better: Care Homes for Adults (18-65 years) Page 8 of 50 Due to a high level of staff change and commitment to two services, the management team was not established or consistent. This had an impact upon the continuation of leadership within the service. Reducing staffing levels during the day and at night had potentially placed people at risk of not having their needs met. The on call system was inadequate to support the service effectively on a long term basis. While staff training had been improved upon, some staff members had not participated in all courses. Due to the complexity of peoples needs and the fact that some of these staff were lone working, the lack of their up to date knowledge, potentially placed people at risk of harm. The staffing roster must be an accurate reflection of the actual staff on duty. The times worked by the management team should be clearly stated. While a new care planning system was being introduced, the information currently available to staff did not fully inform them of peoples complex needs. This particularly applied to peoples health care needs such as epilepsy. Protocols were required for aspects of peoples care such as the administration of epilepsy emergency rescue medicines. Care procedures such as those to minimise soreness must be undertaken as required. Staff must not administer suppositories or any other invasive procedures unless they have been specifically trained and have had their competency assessed by a qualified health care professional. Care charts, such as those which demonstrate peoples seizure activity and fluid intake must be ordered, fully completed and regularly evaluated. While there was less reliance on agency staff, the agency staffs suitability to work with vulnerable people should be evidenced. There should be written evidence of each staff members induction (including agency staff) which has been fully completed and signed off. Staff must receive regular fire instruction so that they are fully aware of the procedures to follow in the event of a fire. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 50 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 50 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People now have up to date information about the service to enable them to decide if it is suitable for their needs. A clear admission process enables people to be assured that their needs will be met. Evidence: People had lived at the service for many years. There was one vacancy at the time of our visit. A team coordinator told us that it was not intended to fill this vacancy until all shortfalls within the service had been addressed. We therefore did not address this outcome area during our visit. The AQAA described the admission process. It stated for a new client, Shapland would conduct a pre-assessment. This can involve carrying out observations, one to one meetings with the individual and discussion with other significant stakeholders or professionals, where appropriate. Information from the pre-assessment is used to develop an in-depth Care profile that contains details and costs specific to the degree and nature of support the individual requires. This information is then translated into a Care Homes for Adults (18-65 years) Page 11 of 50 Evidence: care plan which would detail the support, needs, wishes and aspirations of an individual. It would inform staff of the way in which the individual prefers to have these needs met. We encourage people to visit the service initially to have a look round and perhaps join the other people we support for a meal. After which we would encourage a trial stay for at least one or two nights. This allows the individual to gain a better understanding of the service and how it would feel to live there. It also gives the management team the chance to continue the assessment process and develop the care plan/profile further. If the customer decides the home is right for them, we would then offer a 12 week trial placement which we review after 6 weeks. During this trial period, a key worker is assigned to the individual. At the end of the 12 week trial period a review would be held for all parties to decide whether Shapland is a suitable permanent placement. At our last visit, we made a requirement that the Statement of Purpose was regularly reviewed and contained information, as identified in Regulation 4, Schedule 1 of the Care Home Regulations 2001. We saw that this had been addressed. The AQAA stated that the Statement of Purpose was being developed in more accessible formats. This work was scheduled to be completed by the end of April 2010. The AQAA also stated that the Statement of Purpose and Service User Guide would be reviewed quarterly, or before should there be any significant changes to the service offered. We saw that the Statement of Purpose contained details of the recent reduction in staffing levels. Care Homes for Adults (18-65 years) Page 12 of 50 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The focus on developing care plans and risk assessments should ensure that peoples needs are clearly identified which in turn will promote the individuals safety and general wellbeing. People are encouraged to make decisions yet additional tools could be explored to enable further opportunity. Evidence: At our last inspection, we made a requirement to ensure that care plans were sufficiently detailed and regularly updated to reflect peoples complex care needs. At this inspection, Mrs Irvine told us that new care plan and recording formats had been devised. The AQAA confirmed the changes in care planning. It stated during the process of reviewing the care plans it became apparent that the existing format needed to be redesigned to ensure they were more person centred. Therefore work has commenced on a new format and by working in conjunction with the service user (where possible) and other significant stakeholders such as family and health professionals, we aim to Care Homes for Adults (18-65 years) Page 13 of 50 Evidence: produce person centred plans which will detail the needs, wishes and aspirations of each individual. We saw that work was taking place to review the format of all care plans. Within one plan, there was a review sheet, which stated that the plan had been reviewed in March 2010. The sheet stated care plan rationalised and indexed. Transferred to new format. Sent to [family member] for signing off. The care plan gave details of the person in a pen profile. There was information about the persons likes and dislikes. The plan contained a section on the persons life story and their cultural background. There was a communication sheet, which contained details about the persons prescribed medicines, their medical history and the support they needed with eating and drinking. The care plan gave information about the support the person needed to maintain their personal care routines. We saw that new recording sheets such as daily records and health recording formats were in place yet these had not been completed. Photographs were used to explain aspects such as a persons posture. We saw that while the detail within care plans had been improved upon, there were aspects of peoples health and personal care which were not detailed within the plan. For example, within one persons daily diary it was recorded splints done. There was no evidence of this within the persons care plan. Epilepsy management profiles were in place yet there was no information about the persons epilepsy within their care plan. There were no details of the administration of emergency rescue medicines. At our last inspection, we saw that care charts to monitor peoples seizure activity, sleeping pattern and/or their food and fluid consumption were disorganised and not fully completed. We made a requirement to address this. We said that care charts must be fully completed and evaluated at a frequency, which met the persons needs. During this inspection, we saw that some of the records were not orderly stored so were difficult to find. One person had a record of their seizure activity. Some of the records showed numbered pages yet one page was missing. Other pages showed some seizures yet the dates were not in order. The pages were not numbered so did not form an integral part of the ongoing log. The documentation was not evaluated within the persons care plan. Another person had a chart to monitor their fluid intake. Staff had recorded amounts of fluid which the person had taken within a specific timescale. For example, it was recorded 7am-9am 650mls and 9am-3pm 1000mls. We advised that staff record individual amounts in order to ensure accurate information. The amounts were not totalled and evaluated at the end of each day. We saw that there were some occasions when the person received minimal or no fluid intake. We said that this should have been identified and addressed accordingly. Care Homes for Adults (18-65 years) Page 14 of 50 Evidence: At our last inspection, we said that each segment of the care plan should be dated. This would ensure that all aspects were up to date and an accurate reflection of the persons needs. There was no evidence that this had been addressed. We previously recommended that short-term care plans be used to address current aspects such as a sore/dry area of skin. Mrs Irvine told us that this was being addressed. New reporting formats were being introduced on the 1st April 2010. In relation to equality and diversity, the AQAA stated Scopes whole ethos is about achieving equality for people with disabilities. We ensure all individuals whether customers, employees or volunteers are treated with respect and dignity irrespective of their race, gender, ability, sexual orientation, age or cultural beliefs. This will enable us to offer a range of opportunities and experiences to the people we support. Shapland offers support to a diverse group of people; by ensuring a Person Centred approach we will be able to identify and respond appropriately to the diverse needs of every individual. We are developing care plans which acknowledge and respect the individuality of each person and which also ensures their dignity is maintained throughout all aspects of service provision. The AQAA continued to state we try to encourage and support service users to make choices and decisions about how they wish to live their lives. Even if those decisions are relatively small, such as what an individual would like to wear, eat or how they wish to spend their recreational time. Peoples preferred daily routines were detailed within their care plan. One persons care plan reminded staff do not make assumptions that I cannot make decisions or choices about some aspects of my life. I will let you know if I am ready to get up or not, often I will pull the duvet back over my head if I dont want to get up. Another plan stated I choose and let staff know when I want to go to bed. I do this by trying to get up and grab my walker. Staff members told us that due to having a good knowledge of the people they supported, they were able to identify requests through body language, gestures and sounds. We saw that one person clearly indicated that they wanted to go out for a walk with staff support. We saw that one person was supported to express their needs through the use of pictures. We said that this was an area, which would benefit from being further developed. At our last inspection, we made a requirement that risk assessments must address the complexity of peoples needs and address potential risks such as choking. We said that Care Homes for Adults (18-65 years) Page 15 of 50 Evidence: any accident must be reviewed within the risk assessment process in order to minimise further occurrences. In relation to this, the AQAA stated management will be transferring all existing risk assessments onto the new Scope risk assessment template to improve continuity and clarity. To ensure that the risk management process becomes integral to the every day working practice of all staff, management will ensure that when a new risk assessment is developed, staff will be made fully aware through handover, team meetings and or supervision forums. We saw within care plans that risk assessments had been reviewed and updated. Areas such as bathing, the use of the toilet, pressure area care and trips out were addressed within the risk assessments. One person had a risk assessment about their epilepsy, which stated all staff to be trained in the management of epilepsy and rescue medication. As identified later in this report, not all staff had completed up to date epilepsy training. Another assessment stated that the person needed to be checked every 20 minutes whilst in bed. With the reduction in staffing levels, we said the ability to do this, in the event of another person being unwell, should form part of the risk assessment. Within a survey, a staff member told us the home offers a good standard of care and is a safe and secure residence. Our new manager, Paul Glover is working very well in partnership with the families and relationships are much improved. Care Homes for Adults (18-65 years) Page 16 of 50 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are benefiting from greater focus on meeting their social needs. People are supported to maintain strong links with their families. The provision of home cooked food is improving enabling people to have a more nutritional diet. Evidence: Staff told us that people continued to attend day services within the week at the Douglas Arter Centre. Some people attended each day from Monday to Friday. Others attended on a sessional basis. Some people had one to one staff support so they had day care at home. One person spent some time at another day service for specific chosen activities. They were supported by a staff member from Shapland Close. The staff member told us that the person liked sensory and story telling sessions. They also liked to attend the Mortive Art Group at Salisbury Art Centre. The person indicated that they liked to go to out. Care Homes for Adults (18-65 years) Page 17 of 50 Evidence: Staff told us that one person at their review had indicated that they no longer wished to attend day services. Staff said that the persons care manager was working with them to find alternative options. We asked the person if they no longer wished to attend day services. They confirmed this by putting their thumb up. One member of staff told us XX may benefit from one to one support. I know that they are recruiting more drivers. There is not really enough staff to allow us to go out although we often go out at weekends unless we have staff shortages. We may look at obtaining a bus pass for XX, as they love looking at clothes and going to the hairdressers. During our second day at the service, we saw that one person was going out for coffee with staff support. They were unable to communicate with us verbally, however through facial expression and gestures they indicated that they wanted to go out. Another person was going out to a museum and then having lunch at a fast food restaurant. It was stated within one persons daily records, that they had enjoyed walks to feed the ducks, a trip to the Wilton centre, Tai Chi and trips to local gardens. They had also enjoyed visits to their parents, listening to stories and playing with a ball. Staff told us that some people had visited local Riding for the Disabled stables. They said that people were currently on a waiting list to enable them to regularly undertake this activity. We saw photographs displayed on the notice board of a Christmas party, which had been organised by a local charity. Mr Glover told us that the service had recently received a grant for £1400 from the charity. It was planned for this to be used to go towards peoples holidays and activities. One member of staff told us that they had arranged to do a parachute jump in order to raise money for the service. In relation to what the service did well, the AQAA stated we support service users to maintain strong links with their families and friends (with the individuals agreement). Service users are currently supported to maintain links with the local community by accessing facilities such as church, local restaurants, social clubs, theatre and day centre. We provide specially adapted vehicles to enable service users to access the community with greater ease. We saw that important relationships were noted within the persons care plan. Important events such as family members birthdays were also stated. In relation to what the service could do better, the AQAA stated we need to continue supporting the service users at Shapland close to maintain the community links they already have and to also have the opportunity to experience new opportunities and experiences. Within their survey, a person told us that they could usually make decisions about what to do each day. They said they could do what they wanted to do in the evenings Care Homes for Adults (18-65 years) Page 18 of 50 Evidence: and could sometimes do what they wanted at weekends. Within their survey, in relation to what the service did well, a staff member told us The last couple of months has seen a big turn around with massive improvements in communication throughout staff, service users and relationships with parents. The service users do a lot more activities. Another staff member said supporting people to access the community and offering people choices, were things the service did well. A health care professional told us activities have been developed so people are more involved and engaged. In relation to what the service could do better, a staff member said offer more therapeutic activities. Within the services most recent quality assurance survey, a relative said the residents are not stimulated enough, still rely on the telly to occupy them, they seem tired and bored. Im sure nobody wants Shaplands to become institutialised and everybody must remember it is their home. Perhaps there could be a walk at the weekend. At our last inspection, we recommended that greater focus should be given to communication and how people could be supported to make more decisions. We saw that communication needs were recorded within individual care plans. During our visit, one person did not want to eat their lunch. The staff member said that they would spend time with the person and their communication book. The book could not be easily located. Once located, we saw the staff member use pictures to ascertain if the person was feeling unwell or if they wanted something to eat or drink. The person indicated that they wanted a peanut butter sandwich. The AQAA stated To improve choice and control, particularly for the service users who have limited communication or impaired cognitive abilities, picture prompts are being incorporated into the menu plans and some food items in the kitchens. Though a work in progress, we are hoping to expand the scope of these picture/objects of reference for the people we support. During feedback, we said that expanding on this area would be a positive outcome for people. We said that the pictures in place could be improved upon through being brighter, more interesting and eye catching. We saw that one person assisted staff in the kitchen with meal preparation. Another person sat with staff at the dining room table while staff prepared some vegetables. A staff member told us that one person liked to help make pastry. We saw staff supporting people to eat their lunch. Staff communicated with people while doing so. We saw that one person used a plate guard so that they could eat independently. At our last inspection, we made a requirement to review meal provision to ensure Care Homes for Adults (18-65 years) Page 19 of 50 Evidence: peoples nutritional needs were being met. The AQAA confirmed that this had been undertaken. It stated the Individual dietary and nutritional needs have now been reviewed and personalised menu planning and food provision is in place. Staff told us that they cooked a different meal in each bungalow. People then had a choice of two meals or other snacks. On the day of our visit, breakfast was cereal and toast, boiled eggs and fruit juice. Lunch was jacket potato with various fillings, homemade quiche and soup. The main meal of the day was pork sausages or beef stew with mixed vegetables. For dessert, it was summer pudding and cream. We saw that the Statement of Purpose told people about the arrangements for meal provision and the choices which were available. The document confirmed meals are freshly prepared. While there appeared to be more emphasis on home cooked food, there was still a high level of tinned food in the kitchen cupboards. This included tins of Ravioli, Macaroni Cheese, Big Soup, Irish Stew and various currys. There were minimal basic and fresh ingredients in order to prepare a meal. Mr Glover told us that fresh fruit and vegetables were kept in the garage. We did not look at these food stocks on this occasion. During our inspection, a staff member returned from doing the food shopping. We saw that further ingredients were placed in the refrigerator. We saw that food provision was discussed in one staff members supervision session. The supervision record stated discussed the need to demonstrate to the inspectors that we provide residents with a clear choice at mealtimes. The staff member had suggested could produce new menu... we could then get more organised making sure that the food is available to be cooked by making sure that we enable proper shopping trips to take place with more resident involvement. Within their survey, a staff member told us that improving the quality of food and menus was something the service could do better. Care Homes for Adults (18-65 years) Page 20 of 50 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are at risk of harm and of not having their needs met due to inadequate training and by staff not following procedures as required. The systems to manage peoples medicines do not fully safeguard them from error. Evidence: At our last inspection, we saw that care plans did not reflect the complexity of peoples needs. As stated earlier in this report, new care planning formats and staff training were addressing this. We saw that peoples preferred daily routines were detailed and more person centred. For example, one file stated my appearance is important to me. I prefer to wear smart casual clothes. Another care plan stated I have my hair cut on a regular basis by XX (a staff member.) Mr Glover told us that the staff member was a fully qualified hairdresser. He said that the persons family were happy for this to take place rather than enabling the person to go to a local hairdressing salon. In relation to what the service did well, the AQAA stated Staff at Shapland close have a good knowledge and understanding of the service users. Each service user has an individual care plan that has recently been reviewed and updated... We ensure that we provide or enable service users to access all specialist equipment to enable them to Care Homes for Adults (18-65 years) Page 21 of 50 Evidence: achieve as much independence as possible. Within their survey, a relative told us that the service sometimes met the needs of their relative. They said they were sometimes kept informed of important issues affecting their relative. The AQAA confirmed all service users are registered with the local health practice and staff support them to attend all relevant health care appointments. Service users have good access to specialist health care services. A Community Nurse, from CTPLD [Community Team for People with Learning Disabilities] who is now supporting the service to do develop management plans for those individuals who have Epilepsy. At our last inspection, we made a requirement to ensure Epilepsy Management plans were in place for those people who had epilepsy. Mr Glover told us that this was being addressed. He said the Community Specialist Nurse had been working with people, staff and family members to devise the profiles. We saw that one person had a high level of seizure activity. They had an up to date epilepsy profile and intervention plan in place, which had been completed by the Community Specialist Nurse. The document included protocols for the administration of emergency rescue medicine and an emergency intervention plan. There was a Lifestyle risk assessment to accompany the document. The persons required after care, following a seizure was stated. The assessment stated all existing staff trained in the management of epilepsy and rescue medication and new staff will be trained. All staff to have a good knowledge of status epilepticus. Staff to be trained and up to date in first aid. While recognising these were required control measures to ensure the persons safety, we saw that not all staff had received epilepsy training. The epilepsy plan identified that a range of identified risk assessments were to be in place. Not all areas had been completed. We saw that there was a letter on one persons file from CTPLD. The letter stated that they had enclosed an Epilepsy profile with clear guidelines as to when emergency rescue medication was to be given. There was also an enclosed chart to be completed when rescue medication was given. The information was not in the persons file. Mr Glover told us this was because the medicine had not yet been used. The team coordinator was unable to locate an epilepsy profile and seizure chart for another person. She told us I know everyone has had new ones but they had everyones name on, so they may have been sent back to be changed. Mr Glover provided us with the profiles later in the day. Within peoples care plans, there were body maps, which identified any marks or Care Homes for Adults (18-65 years) Page 22 of 50 Evidence: bruises on the person. We advised that any mark recorded, should be linked to a written entry in the persons care plan. The entry should show an investigation into the possible reasons for the injury. Staff should ensure that any medical intervention required and details of the healing process should also be identified within written information. We saw within one record that a person had a sore area of skin. Staff had noted from the persons care chart, that the procedure to minimise the risk of soreness had not been completed for ten days. Within another record we saw that a person went to the podiatry clinic and was found to have a sore toe. There was no evidence on the persons care plan about this or how the healing process would be managed. At previous inspections, we made a requirement to assess peoples risk of developing a pressure sore. We said that if a risk was identified, control measures must be put in place and clearly evidenced. Within one file it was stated I do not currently have any problems with regard to tissue viability, however concerns about my weight and the fact that I sometimes take a nap during the day, staff must be aware and monitor my skin for indicators of pressure areas. There was no further information for staff on what these indicators might be. Another assessment stated staff to ensure that XX mobilises regularly to ensure that the likelihood of pressure areas remain reduced. Staff to be trained in manual handling to ensure that they are able to walk XX to assist with mobility and prevent prolonged use of the wheelchair. We recommended that staff received training in tissue viability in order to ensure the assessments were accurate and peoples skin integrity was maintained. At previous inspections, we made a requirement that staff must receive up to date training in the administration of suppositories. We said that if training was not available, the responsibility of the procedure must be passed to the district nursing team. Mr Glover told us that the district nurse visited every three days to administer the suppositories. Staff had however signed the medicine administration record and the persons daily diary to say they had undertaken the procedure. There was no evidence that staff had completed recent training in the administration of suppositories. The use of the suppositories was not detailed within the persons care plan. They were not listed under the section prescribed medication. We were concerned that this was unsafe practice and could place people at risk of harm. Mrs Irvine told us she was not aware staff were undertaking the procedure and would ensure that it was stopped. We saw that manual handling risk assessments were in place. These showed the number of staff people needed when being supported with their mobility. We saw that Care Homes for Adults (18-65 years) Page 23 of 50 Evidence: one person needed one to one staff support whilst others needed the support of two staff. One assessment highlighted staff to have up to date training in manual handling and to be aware of equipment needed to assist XX. Another stated all staff to have completed infection control training and up to date training in manual handling. We were concerned that despite being identified as a measure to minimise risk, not all staff had completed the training. We saw that peoples weight was being monitored. One person had a history of being under weight. At our last inspection, encouraging the person to eat was poorly managed. The seriousness of the situation was not identified on the persons care plan. At this inspection, we saw that it was recorded I need to be weighed weekly and I have supplement food drinks twice a day. If I refuse food options please try to offer me other alternatives until I eat. The plan contained a list of the persons favourite foods. The persons weight had been monitored and there were supplies of food supplements in the kitchen cupboards. Records made within the persons daily diary showed that the persons food intake fluctuated from day to day. A health care professional told us care plans have been reviewed and staff are asking for a review of placements in order to ensure they are on the right track. Staff are now taking issues such as the persons significant weight loss seriously. At our last inspection, we made a requirement that guidance from health care professionals must be detailed within the persons care plan and be immediately followed in order to meet the persons needs. The AQAA confirmed that Management will ensure that all service users receive a full health check and medication review annually by their own GP. Any changes to the type or degree of support as recommended by any health professional will be identified and recorded in the care plan and all staff made aware of these changes. Within their survey, a staff member told us that standards had improved in the service, since the last inspection. They said there are better systems in place to monitor medication and safeguarding issues and it feels a safer place to work. At our last inspection, we recommended that peoples medicine regimes should be updated and clearly form part of the persons care plan. This had been addressed in part. There was a list of the persons prescribed medicines within their care plan. As stated above, some emergency rescue medicines were not recorded. One record showed that a person was prescribed a medicine daily yet on their communication sheet, which was to be used in the event of a hospital admission, the medicine was stated as an as required medicine. One care plan showed that the person took their Care Homes for Adults (18-65 years) Page 24 of 50 Evidence: medicines on food so that it was easier to swallow. As good practice, the record stated you need to tell XX if they are having their medication. Never conceal it. At our last inspection, we made a requirement that staff must sign the medication administration sheet to show they had applied a topical cream. This had been addressed. We saw that one person was prescribed a bath additive. There were only three signatures of the same staff member, showing that the bath additive had been used. One person was prescribed a variable dose of paracetamol. We advised that when administered, the actual dose of either one or two tablets was identified on the medicine administration record. Handwritten medicine instructions had generally been countersigned by another member of staff. One record however, stated paracetamol yet there were no instructions for its use. Another person was prescribed two different types of pain relief. There was no guidance to inform staff of when each medicine was to be administered. There were guidelines for the administration of medicines (Nursing Midwifery Council 2004) at the front of the medicine administration file. We advised that this information be updated with more recent guidance, such as that found on our website. At our last inspection, we made a requirement that clear instructions showing the administration of any medicine, must be detailed on the medicine administration record and the persons care plan. The AQAA stated care plans identify any specific health needs, with details of all medication that the service user requires. All staff receive medication training. A system is in place for auditing the administration of medication so that any error or omission can be addressed. We looked at the medicine administration record and found that the emergency rescue medicine was not identified. Another person had been prescribed the same medicine. In this instance, the medicine was identified on the medicine administration record but not on the prescribed medication sheet within the care plan. Mr Glover told us that the emergency rescue medicine was stored in the other bungalow on site. We were concerned about the accessibility of the medicine, especially if it was needed at night. We saw within staff training records that not all staff had undertaken recent medication training. As detailed within the AQAA, any staff member administering medicines must undertake this. Since our last inspection, we have been notified of three medication errors. Two involved staff not signing the medicine administration record so it was not clear whether the person had their medicines as required. The third error involved a person not taking their medicines to their day service. Mr Glover had made a decision that the person could have their medicines later, when they got back to the service. Within an incident form, it was stated that the persons GP had authorised this. Care Homes for Adults (18-65 years) Page 25 of 50 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Following the recent complaint training, staff are now better able to respond to peoples concerns. Ensuring all staff complete training in adult protection would ensure people were further protected from abuse. Evidence: Within their survey, a person told us that they knew who to speak to if they were unhappy. Staff told us within their surveys that they knew what to do if someone had concerns about the home. In relation to what the service did well, the AQAA stated Scope has a comprehensive Complaints procedure which was reviewed in December 2009 and for which all staff will receive refresher training in. We are actively encouraging feedback from family, friends and other stakeholders. We adhere to very robust policies, procedures to ensure the Safe Guarding of all service users, these include the No Secrets, SOVA, Scopes Safe Guarding and Whistle Blowing. We saw that a copy of the complaints policy and procedure was available within the service. We looked at the complaint log and saw that no complaints had been recorded since our last inspection. There was a form in place for recording concerns and satisfactions. One relative had written to the home to express their gratitude for the way staff had looked after their relative, when they became ill. Within the recent Care Homes for Adults (18-65 years) Page 26 of 50 Evidence: Quality Assurance questionnaires, we saw that one relative was asked about the management of complaints. They commented we experienced a very bad example last year. A minor complaint took over 3 months to go through Scopes procedure. At our last inspection, we made a requirement that the services complaint procedure was initiated and followed when any complaint was received. We said that the complainant must be informed of the investigation and the outcome. As no complaints had been made, we were not able to assess this area, during our visit. Within the training matrix we saw that twelve staff had completed complaints training. This was confirmed within the AQAA. The AQAA stated The service is committed to operating a robust complaints management procedure. The acting manager has undertaken complaints handling training. He is clear about the way in which he must manage all complaints received; Scope complaints management system will be followed and time scales adhered to. All staff will have received up to date training on how to handle complaints, to ensure they understand their role and responsibility within the procedure. In relation to what the service could do better, the AQAA stated continue to develop the confidence of other stakeholders in our commitment to responding to concerns, complaints and protection issues. At our last inspection, we saw that staff had not received up to date safeguarding training. We made a requirement to address this. The staff training matrix showed that eleven staff had completed the training in March 2010. A number of staff had not participated. We previously recommended that all staff should sign to demonstrate their receipt of Wiltshire and Swindons safeguarding procedures, No Secrets. There was no evidence that this had taken place. At our last inspection, systems such as staff training, risk management and care planning were inadequate to effectively meet the needs of people and to safeguard them. There was unclear leadership and the skill mix of staff, including the high use of agency, placed people at risk. We saw that improvements had been made in these areas. However, some practices such as the administration of suppositories, placed people at risk of harm. The reduction in staffing levels also gave potential risk of people not having their needs met. Care Homes for Adults (18-65 years) Page 27 of 50 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from an improved environment due to the redecoration and refurbishment of certain areas. The implementation of cleaning schedules has ensured a better standard of cleaning within the home. Evidence: Shapland Close consisted of two purpose built bungalows. Each bungalow had four single bedrooms, a lounge/dining room, a kitchen, bathroom and separate toilet. The bungalows had full disabled access. There were patio doors from the lounge, which opened onto a patio area. The office was located in a separate but adjacent bungalow. The laundry facilities were also in a small room, which was separate from the bungalows. Peoples bedrooms were personalised to a high degree. Flat screen televisions and music centres were positioned at heights, which were suitable for the person. One person had a large frame type bed. Mr Glover told us that discussions had taken place with the person, their family and care manager regarding replacing the bed with a design that was less intrusive. We saw that a persons bedroom door had been repositioned to minimise potential risk. At our last inspection, we said that the standard of cleanliness could be improved upon. We made a requirement to address Care Homes for Adults (18-65 years) Page 28 of 50 Evidence: this. During this inspection, the standard was much improved. However, we recommended that the light pulls in the toilets be replaced, as these were very brown in colour. The hand rail in the toilet was also dirty with brown marks on it. Staff showed us cleaning schedules which had been devised. The cleaning of wheelchairs had been allocated to all staff. We saw that the boiler room, although cleaner remained unlocked. At our last inspection, we made a requirement that the laundry room be refurbished due to a high level of flaking paint and surfaces which were difficult to keep clean. We saw that this had been addressed. The lounge area and corridors of both bungalows had also been redecorated. New flooring was planned. One kitchen had been fully refurbished. We previously recommended that all staff had infection control training. This had been addressed in part as the training had been organised yet not all staff had attended. Mr Glover told us that the Jacuzzi style bath had been repaired although it had broken again. While the bath was working, the jets had been flushed through therefore minimising the risk of legionella. Mr Glover told us that the Jacuzzi part of the bath was always in need of repair although the bath could still be used. Within the AQAA, in relation to what the service did well, it was stated ensure that living environment is safe and appropriate to meet individual needs. Specialist equipment and adaptations are in place to accommodate all individual needs. This is reviewed regularly to ensure that any change in need is responded to quickly and effectively. Regular servicing and maintenance of equipment ensures safe handling and operation at all times. We try to make the environment as homely as possible. Service users are encouraged and supported to personalise and individualise their bedrooms. We have implemented a cleaning schedule that ensures the home remains hygienic, clean and odour free at all times. Ensure a systematic plan of environmental improvements in respect of the general decor and hard and soft furnishings was something the AQAA stated the service could do better. The AQAA also stated a continuous maintenance programme is now in place to ensure that the environment remains safe and pleasant for the people who live at Shapland. Within their survey, a person told us that the home was usually fresh and clean. Care Homes for Adults (18-65 years) Page 29 of 50 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are potentially at risk of not having their needs met through the reduction in staffing levels. While the overall level of staff training has increased, people are being supported by some staff who have had very little up to date training. People are protected by a robust recruitment procedure. Evidence: At our last inspection, we saw there was a very high use of agency staff and staff interactions with people were limited. We made a requirement to review staffing levels to ensure that they met the needs of the people using the service. We said that measures to minimise the use of agency staff must be considered. We also made a requirement to ensure that a review of the skill mix of the staff team was undertaken so that people were supported in a safe, effective manner. In response to the above requirements and the rating of the service moving from good to poor, SCOPE undertook a full staffing review. Mrs Irvine told us that the review highlighted shortfalls in some staff members attitude, knowledge and skills. As a result, some staff were being supported to improve their performance through additional training and supervision. The AQAA confirmed this by stating A staffing review has already identified some staff who are currently not fulfilling the Care Homes for Adults (18-65 years) Page 30 of 50 Evidence: requirements of their role and these individuals will be supported to improve their performance through strong leadership, effective supervision, ongoing training and SMART objective setting. Failure to improve performance will be managed through Scopes Capability and/or disciplinary procedures. Stringent Ill Health management has been invoked to support people to attend work regularly and ensure that they are fit to do the job for which they are employed. This process will help to reduce the use of agency staff and so improve the continuity of care. Whilst the service has a duty to ensure reasonable adjustments in line with the Disability Discrimination Act, management are clear that all staff must be able to support service users in a safe and effective manner. While noting that supporting people in a safe and effective manner was identified within the AQAA, we were concerned to see that as part of the staffing review, staffing levels had been reduced. The sleeping in role at night had been withdrawn and staffing levels were maintained at one waking night staff in each bungalow. Mr Glover told us that the decision to remove the sleeping in role had been made, as the staff member was rarely called upon. In the event of an emergency or if a person was unwell, a memo showed that staff were to contact Mr Glover or another senior staff member for advice. They would then attend the home, to give assistance if required. We were concerned that the reduction of staff at night impacted upon the ability to meet peoples needs safely. For example, if a person had a seizure, there would be a delay before additional staff assistance could be sought. Mr Glover told us that in this instance, immediate medical assistance would be sought so people would not be at risk of harm. Staff told us that the majority of people required the assistance of two staff members for their manual handling needs. This was confirmed within some peoples care plans. We were concerned that having only one staff member on duty impacted on the level of support people received. It also impacted on the flexibility people had with their daily routines. Mrs Irvine told us that these factors had been considered and were not seen as being a problem. Within their survey, a relative told us with the changes in the management team, the situation began to improve. Parents Meetings and Key Team Meetings have recommenced. Communication with management has improved and some long standing problems have been resolved. However, over the last few months a large number of staff have left or resigned, leaving the unit very short staffed. We are now very concerned about the shortage of staff, plus the fact that many of those who are providing the service are new and do not know the residents well. This is increasing Care Homes for Adults (18-65 years) Page 31 of 50 Evidence: the risk that there will be a serious failure in the level of care provided, e.g. during an epileptic seizure. Within the AQAA, it was stated rota provision is flexible and responsive to provide the support that individuals want. However, in contrast, the staffing review also reduced staffing levels during the day. This meant that there were generally two staff on duty during the day, in each bungalow when people were at home. A team coordinator told us that the decision had been made to reduce the staffing levels as the service was not operating at its full occupancy. As stated above, we were concerned about how this impacted upon peoples needs. For example, when people needed the assistance of two staff members to support them with their personal care routines, this left other people unsupported. Due to peoples complex needs, we said the reduced staffing levels could also impact upon the opportunities for people to meet their social needs. We saw that some staff were working lengthy shifts such as 5pm until 8am the next day. Mrs Irvine told us that this had been identified and was in the process of being addressed. Within a quality assurance survey, it was recorded I feel that with new management and staff, Shaplands will go forward, but still feel only two staff on duty when all have to be fed, bathed, do activities plus paperwork and monitor their seizures is not enough. Theres an accident waiting to happen. Within their surveys, all three staff members told us that there were usually enough staff to meet the individual needs of people. While acknowledging that SCOPE had identified the need for change within the staff team, we were concerned that staffing levels had been reduced before all shortfalls within the service had been addressed. Staff told us that there were no team coordinators in post at the service. Team coordinators from another SCOPE service in Salisbury were providing supervisory cover. A change in their contract enabled them to work across SCOPE services, when required. We saw that they were not identified on the staffing roster. The staffing roster showed Mr Glover as being on duty yet he was at a managers meeting. A team coordinator told us that a manager was on duty each day. We were concerned of the continuity of leadership due to all four managerial staff working across two units. The team coordinator told us that this did not appear to be a problem. They said that working across services enabled them to get to know people better. Care Homes for Adults (18-65 years) Page 32 of 50 Evidence: The team coordinator and other staff members told us that in addition to the management team, a shift leader was delegated to manage day to day provision. We advised that their role was identified on the staffing roster. They said the shift leader ensured that the shift ran smoothly and tasks were allocated to staff. They said the shift leader was also responsible for administering medicines, making any appointments, interacting with health care professionals and generally ensuring peoples wellbeing. The shift leader was counted as an integral member of the team who also supported people with their personal care routines. The AQAA showed that fifteen staff had left in the last twelve months. Two staff were on long term sick leave. Mr Glover and the team coordinator told us that there had been two new staff since the last inspection. They said that six new staff had been recruited yet were awaiting clearance to ensure they were suitable to work with vulnerable people. We saw that despite staffing vacancies and staff being on long term sickness leave, there was a reduction in the amount of agency staff identified on the staffing roster. The team coordinator told us that some staff had chosen to do extra shifts above their contracted hours. The reduction in staffing levels had also enabled less agency use. The AQAA stated Shaplands employs a diverse workforce with a mix of skill, knowledge, gender, age, race and culture; this enables us to provide a range of opportunities and new experiences to the people we support. Within their survey, a person told us that staff always treated them well. They said that staff always listened and acted upon what they said. In relation to what the service could do better, a staff member said clearly define staff roles and structure. Another staff member said Shapland could benefit from more reliable staff and also more staff that care and put the service users first. We also need at least two team coordinators. At our last inspection, we made a requirement that staff must receive up to date training in safeguarding and all other mandatory subjects such as first aid, food hygiene, manual handling, the safe handling of medicines and infection control. We saw within staff training records that a high level of training had been organised. Staff members confirmed this. Wiltshire Quality Team told us that they had facilitated training in care planning and Dignity in Care. An external training provider had provided training in Moving and Handling. This was linked to the complexity of peoples needs. At our last inspection, we said that staff must attend the moving and handling training and it must not be cascaded within the staff team. Mrs Irvine told us that this had taken place. The increase in staff training was confirmed within the AQAA. It stated since the last Care Homes for Adults (18-65 years) Page 33 of 50 Evidence: inspection staff have attended numerous mandatory training courses such as: Moving and Handling, Medication, Fire Safety, infection control, as well as complimentary training such as: Communication, Dignity in care. All staff have received Moving and Handling training by a competent trainer. We looked at the staff training matrix and saw that eleven staff had completed moving and handling training. Ten staff had not. Ten staff were up to date with first aid training yet there was no evidence that the remainder of the team had undertaken training in this area. Eight staff had completed health and safety/risk assessment and the control of substances hazardous to health (COSHH) training in January of this year. While safeguarding, infection control, epilepsy awareness and communication training had been organised, not all the staff team had participated. There was no evidence within the training matrix that training in the safe handling of medicines had been arranged. Mrs Irvine told us that a clear focus had been given to staff training. She said that she was sure that staff had undertaken more courses than stated within documentation. At our last inspection, we recommended that training documentation should be reviewed to ensure it was an accurate reflection of the training staff had completed. From what Mrs Irvine was saying, it was not clear whether the recommendation had been met or not. Within the AQAA, it stated an effective Training Needs Analysis and Training Matrix are constructed to ensure that the service is providing suitable and relevant training. We ensure that every member of staff receive all mandatory and complimentary training, so that we have an appropriate skill and ability mix within our staff team. The AQAA confirmed that 13 out of the 21 staff had NVQ level 2 or above. We looked at the training records of specific members of staff. We saw that one staff member had not completed any up to date training. The training record showed they had undertaken the safe handling of medicines training in August 2008. They had also completed first aid and food hygiene training in 2006. Another waking night staff member had no evidence of first aid or epilepsy training. We were concerned that these staff members were working alone with full responsibility of meeting peoples needs, without up to date training in key areas. We saw that the lack of attendance at training events had been addressed with one staff member in supervision. The record stated it is difficult for XX to attend staff meetings and training sessions due to personal commitments. While acknowledging this, we said that it was managements responsibility to ensure that all staff had the knowledge and skills to meet peoples needs effectively. Without this, people were being placed at risk of harm. The AQAA stated All staff have received a considerable amount of training since the Care Homes for Adults (18-65 years) Page 34 of 50 Evidence: last inspection to ensure that their working practice is up to date and safe. For example; 8 staff have already been trained in the administration of suppositories. Further training has been booked for 15 more staff to undertake this training which incorporates an assessment of competency. This will ensure that the administration of suppositories to individuals who require it (as identified in their care plan) is carried out in a safe, professional and dignified manner. There was no evidence of this training within documentation. Mr Glover told us that accessing the training had been difficult. He showed us a memo from a Community Specialist Nurse. This stated that the nurse would be happy to facilitate the training yet due to workloads, there would be a delay in arranging the sessions. As stated earlier in this report, we saw that some staff were administering suppositories without up to date training. This placed people at risk of harm. Mrs Irvine told us that she was not happy for staff to administer suppositories and would therefore make alternative arrangements so that staff would not undertake the procedure. At our last inspection, we recommended that staff should receive up to date training in relation to peoples needs. We said this should include person centred care, learning disability, communication, tissue viability, eating and drinking and catheter care. We saw that training in communication and person centred care had been arranged. There was no evidence that the other topics had been addressed. At our last inspection, we made a requirement that senior staff must receive training in relation to their role. We said that this must include training in topics such as risk management, staff supervision and recruitment procedures. Within the training matrix, other than risk assessment, there was no evidence that the other topics had been addressed. A new member of staff told us that their induction had been useful and informed them of what they needed to know to do their job. They said it was a good basis but you also learn when you are going along, especially with the people here. I shadowed a member of staff for a few weeks. This was really useful, as it enabled me to see how other staff communicated with people. We saw that the induction programme consisted of health and safety issues such as fire safety. It also covered the support people needed to meet their personal care routines. The staff member and their supervisor had signed to authorise that they had supported a person with various daily living tasks. The support the person needed in the evening and key aspects such as epilepsy and the completion of care charts had not been completed. Within surveys, two staff members told us that their induction mostly covered everything they needed to know to do their job. One member of staff said it partly Care Homes for Adults (18-65 years) Page 35 of 50 Evidence: covered what they needed to know. Within the AQAA, it was stated that induction was something the service said they did well. The AQAA said all new staff as part of their induction, are shadowed by an experienced member of staff. During their induction period, staff are superfluous, and therefore not counted in the staffing establishment. This is a strategy implemented by the home to lessen the risk of service user care being compromised and to give the maximimum opportunity to new staff to become fully conversant with service user needs before working independently. We asked the team coordinator about the induction programmes for agency staff. The team coordinator told us that they also shadowed permanent staff members until confident. There was no written induction in place for the agency staff used. There was also no information to show that the agency staff were suitable to work with vulnerable people. The team coordinator told us that the service had a contract with particular agencies. They said that the agency held all information about the staff members recruitment, their induction and their training. The team coordinator told us that this information could be accessed as required. We recommended that a summary of information be held within the service, so that the manager could be assured of the agency members suitability. The AQAA confirmed Management have undertaken a full review of the existing staffing establishment. They recognise the need to ensure that all staff have a clear understanding of their role and their responsibilities within the service. The staff must understand the principles of person centred service provision and be able to apply this ethos to their own working practice. The AQAA stated we operate a recruitment procedure and selection process that ensures only competent and suitable skilled staff are employed subject to satisfactory employment checks and in line with Equal opportunities. Mrs Irvine told us that the selection process had recently been more robust. She said that only applicants who fully met the identified requirements were selected. We looked at the recruitment documentation of the two most recently appointed members of staff. The files contained the required information such as an application form and two written references. There was a medical declaration, which showed that the prospective staff member was physically and mentally fit to do the job. Documentation showed that both applicants had been checked to ensure their suitability to work with vulnerable people. We saw from staff files that formal staff supervision had been re-started. Within some files it was recognised that previous sessions had been inconsistent. Documentation stated that due to this, supervision would start from now. The AQAA stated regular Care Homes for Adults (18-65 years) Page 36 of 50 Evidence: supervision and appraisal system is now in place to encourage a proactive and supportive working environment. Regular handover, monthly team meetings, management meetings, encourage trust, honesty and open communication. It also ensures that staff are well informed, involved and take ownership of strategies employed by the service to improve service provision. Care Homes for Adults (18-65 years) Page 37 of 50 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. While improvements have been made to the service, the structure of management is not conducive to effective, consistent leadership. People are benefiting from the improvements being made yet further work is required to ensure the developed systems are fully implemented. The introduction of a quality assurance system has enabled people to formally give their views about service provision. People are better protected through greater focus on health and safety systems. Evidence: At our last inspection, Mr Glover had been newly appointed as a team co-ordinator. He was then appointed, as the acting manager following the resignation of the previous manager. Mrs Irvine told us that interviews had taken place for the permanent managers position yet applicants had been unsuitable. The post was being readvertised. Until the post was filled, Mr Glover was continuing in his role as acting manager. Mrs Irvine a registered manager of another SCOPE service had been seconded to the service to assist Mr Glover. The AQAA confirmed this by stating the acting Service manager is providing strong leadership and guidance to the staff team. Giving clear directives and setting high standards of service provision and leading by Care Homes for Adults (18-65 years) Page 38 of 50 Evidence: example. Additional support has been resourced by the organisation by assigning a manager from an Excellent rated service to help implement the changes that are necessary to move the service forward. In relation to what the service did well, the AQAA stated the acting service manager whilst relatively new to the organisation, has sound knowledge base, experience and the apptitude to enable him to manage the home effectively. The acting Manager is committed to ensuring service users, preference, choice and rights are at the centre of service provision. The acting Manager ensures that the staff team adhere to the necessary policies, procedures and risk assessments in place, which collectively safeguard and protect both service user and staff. The acting Manager ensures that a safe living and working environment is maintained at all times. The acting Manager has developed good working relationships with the families of service users. When SCOPE completed a major restructuring process, the managers role changed to that of being responsible for two services. It was expected that the manager would split their time equally between the two services. The staffing roster showed that Mr Glover was on duty between 9am and 5pm every weekday at Shapland Close. He was also on call every night. As stated earlier in this report, we said that this arrangement could not be successfully maintained on a long term basis. We said that consideration should be given to alternate, more sustainable arrangements. As stated in the staffing section of this report, the management team consisted of the manager and two team coordinators. The team coordinator roles were vacant at the time of our inspection. They were being covered by team coordinators of another service. Within a survey, a staff member told us Shapland has dramatically improved and developed since Paul Glover has taken over the service. I strongly believe that if Shapland is going to recover from its poor rating, then Paul Glover should be made the permanent and substantive manager. I cannot speak highly enough of the contribution he has made to Shapland. The staff member continued to state all of the below listed things have improved under Paul Glovers management: Staff supervision. Staff training. Staff development. Standards of care. Communication. Relationships with parents. Activities. Staffing levels/skill base. Shift organisation and responsibilities. Within their survey, another staff member told us the last two months have been an enjoyable period at Shapland due to the arrival of Paul Glover. His management, direction and commitment has given the whole place a lift and the staff team now Care Homes for Adults (18-65 years) Page 39 of 50 Evidence: believe the future is bright. I for one, would like you as an inspector to recognise Pauls efforts, as standards really have improved under his management. A relative told us, within their survey the manager who was in charge of Shapland at the time of the October Inspection subsequently resigned towards the end of November. An interim manager was then appointed. He had a much warmer personality and with help from the consultant, he immediately began to change the atmosphere at Shapland. However, at the same time he was also given responsibility for the unit at XX. This inevitably reduced the time he could devote to Shapland. In the week before Christmas the consultant was withdrawn and a manager from another Scope unit, Carrie Irvine, was asked to assist the interim manager. This has led to further efforts to improve the service. It is therefore clear that Scope has attempted to respond to the adverse Inspection Report. At our last inspection, we made a judgement that people were receiving poor quality outcomes. Systems such as care planning, risk assessment and staff training were poor. Staffing levels were minimal and there was a high reliance on agency staff. We made twenty two requirements and ten recommendations in order to address the shortfalls within the service. As a result of this, SCOPE seconded a consultant to undertake an investigation of the service. An action plan was devised and we received an improvement plan as requested, which showed how the shortfalls in service provision were to be addressed. During this inspection, we saw that some areas had been addressed while others were work in progress. There had therefore been developments in the standard of the service people received. While progress had been made in some areas, we were concerned that certain practices were taking place. This included the administration of suppositories without staff having adequate training. Also that a staff member was in sole charge of a shift yet was not trained in key areas such as first aid, manual handling, fire safety and epilepsy awareness. We were concerned that staffing levels had been reduced at a time when improvements to the service had not been fully established. We discussed these aspects with Mrs Irvine and Mr Glover during feedback at the end of the inspection. At our last inspection, we saw that the service did not have an ongoing quality assurance system in place. We made a requirement to address this. Mrs Irvine told us that a system had been developed and was being implemented. She said that surveys had been sent out to peoples families but not all had been returned. Mrs Irvine told us that once received, peoples views would be co-ordinated and acted upon. As part of the quality assurance system, Mrs Irvine told us that parents meetings had been Care Homes for Adults (18-65 years) Page 40 of 50 Evidence: reinstated. These were seen as valuable forums for people to share their views and raise any concerns if required. In order to ensure that the views of people were promoted and incorporated into the service, the AQAA stated Scope believe that seeking and valuing the views and opinions of the people we support is fundamental to providing a quality Person Centred service. In the past Shapland Close has not always been consistent in its methods of obtaining this feedback from stakeholders. It has now developed Quality Assurance feedback questionnaire which it will issue to all stakeholders. The information obtained from these questionnaires will be collated and translated into a report which will be made available for all stakeholders. Management recognise the difficulty in obtaining feedback from some of the service users and have accessed support from the Swan and Advocacy Organisation to help them develop more accessible methods. We saw that regular visits as part of regulation 26 had taken place. One person had been asked about the quality of the service they received. It was recorded that the person responded positively by nodding. Within the record of visits, there was no evidence of an action plan which linked to the improvement plan, submitted to us. There was also no evidence of the action plan, which was drawn up following previous safeguarding alerts. We recommended that these aspects be checked upon within the regulation 26 visits. We saw that the regulation 26 visits had identified that assessments in relation to the control of substances hazardous to health (COSHH) dated back, as far as 2000. Staff told us that new data sheets had been requested. All generic environmental risk assessments had recently been reviewed. A risk assessment regarding the removal of radiator covers to enable more heat had been completed. There was an up to date lifting/handling risk assessment in place and each person had an individual assessment in relation to their moving and handling needs. An infection control risk assessment had been undertaken in January 2010. We saw that staff members were observed using disposable gloves when preparing the lunch. Documentation showed that the testing of the portable electrical appliances was scheduled for August 2010. We saw that a Clearwater risk assessment and a water hygiene report had been undertaken. The accompanying letter stated that the results of the water testing would not be released until the invoices payment. There were records in place to show the daily monitoring of the refrigerator and freezer temperatures. Cleaning schedules, which included the cleaning of shower heads, had been devised. Mr Glover told us that he had recently completed an in depth residential training course regarding health and safety. Mr Glover said that as a result, he was Care Homes for Adults (18-65 years) Page 41 of 50 Evidence: implementing various systems within the service. This included the safety checks and regular maintenance of all wheelchairs. We saw that the regulation 26 visits had identified that there had been some delay in undertaking some fire safety checks. At our last inspection, we made a requirement that each staff member must take part in a regular fire drill so that they knew how to respond in the event of a fire. Mr Glover told us that fire drills were taking place. We looked at the records and saw this was so. However, not all staff, such as the waking night staff we previously identified in the staffing section of this report, had participated within a drill. There was a fire risk assessment in place. There was no evidence within the fire log book that staff had received regular fire instruction. Mr Glover told us that he would address this. At our last inspection, staff had not received up to date manual handling training and we saw some poor manual handling practice. We made a requirement to review manual handling practices to ensure people were being supported effectively and safely. As stated earlier in this report, manual handling training by a specialised provider had been arranged. Not all staff attended so further training is required. We did not see any evidence of poor manual handling at this inspection. One person was supported with their mobility, as stated within their care plan. Care Homes for Adults (18-65 years) Page 42 of 50 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 6 12(1)(a) Care charts must be fully completed and be evaluated at a frequency which meets the persons needs. 14/10/2009 2 6 15 Care plans must be 31/12/2009 sufficiently detailed and regularly updated to reflect peoples complex care needs. Guidance from health care 14/10/2009 professionals must be detailed within the persons care plan and be immediately followed in order to meet the persons needs. Consideration must be given 31/12/2009 to assessing peoples risk of developing a pressure sore. If a risk is identified, control measures must be put in place and clearly evidenced. Staff must receive up to date 31/12/2009 training in the administration of suppositories. If training is not available, the responsibility of the procedure must be passed to the district nursing team. Clear instructions showing 14/10/2009 3 19 12(1)(a) 4 19 12(1)(a) 5 19 12(1)(a) 6 20 13(2) Care Homes for Adults (18-65 years) Page 43 of 50 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action the clear administration of any medication, must be detailed on the medication administration record and the persons care plan. 7 35 18(1)(c) Senior staff must receive 31/01/2010 training in relation to their role. This must include training in topics such as risk management, staff supervision and recruitment procedures. Each staff member must take 14/10/2009 part in a regular fire drill so that know how to respond in the event of a fire. 8 42 23(4)(e) Care Homes for Adults (18-65 years) Page 44 of 50 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 6 12 All care charts must be ordered and fully completed so that they can be evaluated effectively. So that the persons needs can be monitored and met accordingly. 30/04/2010 2 6 12 Staff must evaluate care charts and identify when for example a person is not drinking sufficiently. There must be a protocol in place which informs staff of what they need to do to ensure the persons well being. So that the person is not at risk of dehydration or at risk of harm. 30/04/2010 3 6 15 Staff must ensure that all 30/05/2010 care plans fully reflect the complexity of peoples needs and the support they require to meet their personal and health care needs. Care Homes for Adults (18-65 years) Page 45 of 50 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action So that staff have the required information to support people safely and effectively. 4 18 12 Staff must ensure that they consistently carry out any identified care procedure, which is required to meet the persons needs. So that the persons well being is maintained. 5 19 12 Staff must not administer suppositories to people unless they have received up to date training and their competency has been assessed by a qualified health care professional. So that people are not at risk of harm. 6 20 12 Staff must review the 30/04/2010 storage and administration procedure of emergency rescue medication in relation to staff sole working at night. So that people recieve intervention without delay in the event of a seizure. 7 23 13 All staff must receive up to 30/05/2010 date training in safeguarding vulnerable people. 30/04/2010 30/04/2010 Care Homes for Adults (18-65 years) Page 46 of 50 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action So that people are protected from abuse. 8 32 18 A risk assessment regarding 30/05/2010 peoples health and personal care needs and the reduction in staffing levels at night must be in place for each person. So that any risks to peoples wellbeing in relation to the reduction in staffing levels, are addressed accordingly. 9 32 18 A review of the staffing roster must take place to ensure that staff working alone have the required knowledge and skills, through up to date training, to meet peoples needs effectively. So that peoples needs are met by qualified, competent staff. 10 42 13 All staff, especially those 30/04/2010 who work on their own must take part in regular fire drills. So that they are fully aware of the procedures to follow in the event of a fire. 30/05/2010 Care Homes for Adults (18-65 years) Page 47 of 50 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 11 42 23 All staff must receive fire instruction on a regular basis. To ensure that they are fully aware of the procedures to follow in the event of a fire. 30/04/2010 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 6 Staff should ensure that they record a persons actual fluid intake rather than documenting the full amount of fluids taken over a period of time. Staff should develop the use of pictures and other communication tools in order to enable people to be more involved in decision making. Staff should ensure that the development of social opportunities continues in order to enable people to have a varied quality of life. Staff should ensure that communication systems are further developed to enable people to have greater decision making opportunities. Information about particular areas prone to pressure sores should be highlighted within tissue viability risk assessments. Staff should receive training in tissue viability so that risk assessments are accurate and staff have the knowledge to promote healthy skin. When adminstering a medicine that has a variable dose, staff should document the actual amount given on the medicine administration record. In the event of a person being prescribed two different pain 2 7 3 12 4 16 5 19 6 19 7 20 8 20 Care Homes for Adults (18-65 years) Page 48 of 50 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations relief medications, guidance regarding their administration, should be in place. 9 23 All staff should sign to demonstrate their receipt of Wiltshire and Swindons safeguarding procedures, No Secrets. The light pulls in the toilets should be replaced in order to minimise the risk of infection. The grab rail in the toilet should form part of a cleaning schedule so it is maintained to infection control standards. The staff member responsible for the running of the shift should be clearly identified on the staffing roster. Consideration should be given to the on call system so that the manager does not take full responsibility of this. The staffing roster should be an accurate account of the actual staff on duty. The roster should show the deployment of the team coordinators, even though they may be from another service. Written documentation should be available to show that all agency staff are suitable to work with vulnerable people. The training matrix should include details of when staff need refresher training in the identified subjects. Staff should receive up to date training in relation to peoples needs. This should include person centred care, learning disability, communication, tissue viability, eating and drinking and catheter care. Training documentation should be reviewed to ensure it is an accurate reflection of the training staff have undertaken. A written record of each agency staff members induction programme should be maintained. All programmes of both agency and permanent staff should be fully completed and signed off. Priority should be given to creating a stable, management team in order to ensure consistent leadership. 10 11 12 13 14 30 30 32 32 32 15 16 17 34 35 35 18 19 35 35 20 37 Care Homes for Adults (18-65 years) Page 49 of 50 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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