Review of compliance. Islington Social Services Islington Social Services - 3 Wray Court. London. Region:

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1 Review of compliance Islington Social Services Islington Social Services - 3 Wray Court Region: Location address: Type of service: London Islington Council Housing and Adult Social Services Department 3 Wray Court, Tollington Place London N4 3QS Care home service without nursing Date of Publication: September 2012 Overview of the service: 3 Wray Court is a home providing residential care for eight people with learning difficulties, run by Islington Council's Social Services department. Page 1 of 16

2 Summary of our findings for the essential standards of quality and safety Our current overall judgement Islington Social Services - 3 Wray Court was not meeting one or more essential standards. Action is needed. The summary below describes why we carried out this review, what we found and any action required. Why we carried out this review We carried out this review as part of our routine schedule of planned reviews. How we carried out this review We reviewed all the information we hold about this provider, observed how people were being cared for, talked to staff and talked to people who use services. What people told us The majority of people who use the service had limited verbal communication. We spoke with two of the people who were able to talk with us and spent time observing the care being provided. One person told us the home and staff were "nice" and that they liked living there. We saw positive interaction between the people using the service and staff members, who asked the people's wishes and dealt with them respectfully and sensitively. People using the service appeared relaxed and comfortable. A number of key documents were either out of date or missing from the home's files providing insufficient evidence that all the people using the service were having their care needs met. What we found about the standards we reviewed and how well Islington Social Services - 3 Wray Court was meeting them Outcome 04: People should get safe and appropriate care that meets their needs and supports their rights The provider was not meeting this standard. The absence from the files of up to date risk assessments and care plans meant there was a risk to people living in the home that the planning and delivery of care would not meet their current individual needs. We judged that this had a moderate impact on the people using the service. Outcome 07: People should be protected from abuse and staff should respect their Page 2 of 16

3 human rights The provider was meeting this standard. People who use the service were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent it from happening. Outcome 10: People should be cared for in safe and accessible surroundings that support their health and welfare The provider was meeting this standard. People who use the service, staff and visitors are protected against risks of unsafe or unsuitable premises. Outcome 11: People should be safe from harm from unsafe or unsuitable equipment The provider was meeting this standard. People who use the service are protected from unsafe or unsuitable equipment. Outcome 13: There should be enough members of staff to keep people safe and meet their health and welfare needs The provider was meeting this standard. There were enough qualified, skilled and experienced staff to meet the people's needs. Outcome 16: The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care The provider was meeting this standard. The provider had an effective system to regularly monitor and assess the quality of the service that people receive. Actions we have asked the service to take We have asked the provider to send us a report within 14 days of them receiving this report, setting out the action they will take. We will check to make sure that this action has been taken. Where we have concerns we have a range of enforcement powers we can use to protect the safety and welfare of people who use this service. When we propose to take enforcement action, our decision is open to challenge by a registered person through a variety of internal and external appeal processes. We will publish a further report on any action we have taken. Other information Please see previous reports for more information about previous reviews. Page 3 of 16

4 What we found for each essential standard of quality and safety we reviewed Page 4 of 16

5 The following pages detail our findings and our regulatory judgement for each essential standard and outcome that we reviewed, linked to specific regulated activities where appropriate. We will have reached one of the following judgements for each essential standard. Compliant means that people who use services are experiencing the outcomes relating to the essential standard. Where we judge that a provider is non-compliant with a standard, we make a judgement about whether the impact on people who use the service (or others) is minor, moderate or major: A minor impact means that people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly. A moderate impact means that people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. A major impact means that people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly. Where we identify compliance, no further action is taken. Where we have concerns, the most appropriate action is taken to ensure that the necessary changes are made. More information about each of the outcomes can be found in the Guidance about compliance: Essential standards of quality and safety Page 5 of 16

6 Outcome 04: Care and welfare of people who use services What the outcome says This is what people who use services should expect. People who use services: * Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights. What we found The provider is non-compliant with Outcome 04: Care and welfare of people who use services. We have judged that this has a moderate impact on people who use the service. Our findings What people who use the service experienced and told us A person using the service said they enjoyed that activities arranged for them by the home. Most of the people received one-to-one care. We observed that the staff worked well with the people, having established trust, and they were skilled in dealing with people who were non-verbal or had complex communication needs. Other evidence We spoke with a care manager for one of the people using the service. Although they were newly appointed and their experience of the home limited, their opinion was very positive. We looked at the personal files of three of the people using the service. They contained details of life history, guidance on communication and behaviour, personal care routine, health and medical needs, preferred food and the activities they enjoyed. There was a list of the key workers for each person, together with other health and social care professionals and their contact details and evidence of regular healthcare appointments. The deputy manager told us that two people's care plans (called by the home "residential reviews") had been reviewed in November 2010 and October 2011 respectively. However, details were missing from the files when inspected. We asked Page 6 of 16

7 the deputy manager about this, but they did not know the whereabouts of the documents. The deputy manager told us after the inspection that one set of care plan minutes had been found, but the other was still missing. The review of the person's care plan dating from November 2010 was in any event well overdue. We were subsequently told by the manager that the care plan had been reviewed in February Similarly, a number of risk assessments (which the home calls "risk analyses") on the people's files had not been reviewed for at least two years. The matter of the outdated risk assessments had been noted at the previous inspection, in July 2011, but this had not yet been addressed as the manager had told us that new risk assessments were being introduced. We saw a report of a visit in October 2011 by one of the provider's senior managers, in which it was stated that the risk assessments were "very out of date." In another report of a senior manager's visit in January 2012, it was stated that it should be a "priority to update service user records." In the report of another visit made in May 2012, it said that there had been some "progress with the support plans. " Daily records were kept for each person using the service and these were transcribed as monthly summary sheets. However, one person's summary sheets for June and July 2012 were absent from the files, as were those for another person for July and August 2011 and February, June and July We saw people involved in a number of activities, including cooking and art. One was accompanied by a staff member on a trip out. Others were relaxing around the home and in their rooms. The files of the people using the services listed activities away from the home including gym, swimming and trampoline sessions, cycling and bowling. The staff members we spoke with said that other activities included bus trips, visits to museums and meals out. We noted that most of the home's permanent staff had worked there for many years and that they would be familiar with the people's care needs. In addition, the feedback from the care manager was positive and the standard of care observed was good. Out of date risk assessments and the absence from the files of some monthly summary sheets and care plans, meant there was a risk of staff not having the correct information to guide how they provide care to the people using the service. The provider was not meeting this standard. The absence from the files of up to date risk assessments and care plans meant there was a risk to people living in the home that the planning and delivery of care would not meet their current individual needs. We judged that this had a moderate impact on the people using the service. Page 7 of 16

8 Outcome 07: Safeguarding people who use services from abuse What the outcome says This is what people who use services should expect. People who use services: * Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld. What we found The provider is compliant with Outcome 07: Safeguarding people who use services from abuse Our findings What people who use the service experienced and told us The person we spoke with said they felt safe at the home. The care we observed was relaxed and the people appeared very comfortable with the staff. Other evidence The staff members we spoke with regarding this standard showed a good understanding of safeguarding issues and procedures. We saw evidence that most staff had received relevant recent training. However the provider may find it useful to note that three staff members had not received refresher training in safeguarding for at least four years. Since the last inspection the staff working in the home have recognised potential safeguarding issues and have alerted them correctly and this protects the safety and welfare of people living in the service. The provider was meeting this standard. People who use the service were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent it from happening. Page 8 of 16

9 Outcome 10: Safety and suitability of premises What the outcome says This is what people should expect. People who use services and people who work in or visit the premises: * Are in safe, accessible surroundings that promote their wellbeing. What we found The provider is compliant with Outcome 10: Safety and suitability of premises Our findings What people who use the service experienced and told us We spoke to people using the service but their feedback did not relate to this standard. Other evidence We saw evidence that testing of the fire alarm was carried out and recorded on a weekly basis, confirming that a compliance action made following the previous inspection had been met. The fire safety risk assessment we saw on file was dated January Since then a small patio garden has been put in place at the southern end of the building, which is used as an escape route. The provider may find it useful to note that a new fire risk assessment should be undertaken. The provider was meeting this standard. People who use the service, staff and visitors are protected against risks of unsafe or unsuitable premises. Page 9 of 16

10 Outcome 11: Safety, availability and suitability of equipment What the outcome says This is what people should expect. People who use services and people who work in or visit the premises: * Are not at risk of harm from unsafe or unsuitable equipment (medical and non-medical equipment, furnishings or fittings). * Benefit from equipment that is comfortable and meets their needs. What we found The provider is compliant with Outcome 11: Safety, availability and suitability of equipment Our findings What people who use the service experienced and told us We spoke to people using the service but their feedback did not relate to this standard. Other evidence Evidence of the recent PAT testing of electrical appliances was seen. However, the provider may find it useful to note that there was no record of the equipment in the home's sensory room being included. Wall mounted hoists were seen in a number of rooms. The deputy manager informed us that these were not in use as they were not needed for the people currently living at the home. Should that situation change, the provider should arrange for the hoists to be checked by a competent person before they are brought back into service and that staff are sufficiently trained in their operation. The provider was meeting this standard. People who use the service are protected from unsafe or unsuitable equipment. Page 10 of 16

11 Outcome 13: Staffing What the outcome says This is what people who use services should expect. People who use services: * Are safe and their health and welfare needs are met by sufficient numbers of appropriate staff. What we found The provider is compliant with Outcome 13: Staffing Our findings What people who use the service experienced and told us We spoke to people using the service but their feedback did not relate to this standard. Other evidence The deputy manager informed us that there were twelve permanent care staff and that three full time vacancies had recently been filled. Two posts remained vacant. Cover had been and would continue to be provided by agency or bank staff. Four carers worked during the morning, five in the afternoon and four at night. Two members of staff we spoke with thought that the staffing levels were adequate. One said that there were occasionally busy times, but said that the care provided was not adversely affected. We saw a report of a visit to the home by one of the provider's senior managers in May 2012, which highlighted the need for formal supervision meetings with staff and evidence that this had been put in place. Annual appraisals for all staff had been carried out. Staff we spoke to said they were well supported by management and had access to regular training. We saw evidence of staff receiving training in mandatory subjects and in specialist areas to enable them to meet the specific needs of the people living in the home. The provider was meeting this standard. There were enough qualified, skilled and Page 11 of 16

12 experienced staff to meet the people's needs. Page 12 of 16

13 Outcome 16: Assessing and monitoring the quality of service provision What the outcome says This is what people who use services should expect. People who use services: * Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety. What we found The provider is compliant with Outcome 16: Assessing and monitoring the quality of service provision Our findings What people who use the service experienced and told us We spoke to people using the service but their feedback did not relate to this standard. Other evidence At the previous inspection, we were told that the provider had developed a quality monitoring tool, but that it had not been implemented. As a consequence, an improvement action was set. At this inspection, we saw evidence of visits by senior managers at regular intervals to check on the care provision, confirming that the improvement action had been met. However, the provider may care to note that not all of the recommendations made by the senior managers had been fully implemented. We saw a record of three complaints made since the last inspection. These were appropriately investigated and satisfactorily concluded. The provider took account of comments and complaints to improve the service. The provider was meeting this standard. The provider had an effective system to regularly monitor and assess the quality of the service that people receive. Page 13 of 16

14 Action we have asked the provider to take Compliance actions The table below shows the essential standards of quality and safety that are not being met. Action must be taken to achieve compliance. Regulated activity Regulation Outcome Accommodation for persons who require nursing or personal care Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 04: Care and welfare of people who use services How the regulation is not being met: The provider was not meeting this standard. There was not sufficient evidence that the provider had carried out assessments of the needs of all of the people who use the service and that their needs had been met and their rights protected. We judged that this had a moderate impact on the people using the service. The provider must send CQC a report that says what action they are going to take to achieve compliance with these essential standards. This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations The provider's report should be sent to us within 14 days of the date that the final review of compliance report is sent to them. Where a provider has already sent us a report about any of the above compliance actions, they do not need to include them in any new report sent to us after this review of compliance. CQC should be informed in writing when these compliance actions are complete. Page 14 of 16

15 What is a review of compliance? By law, providers of certain adult social care and health care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The Care Quality Commission (CQC) has written guidance about what people who use services should experience when providers are meeting essential standards, called Guidance about compliance: Essential standards of quality and safety. CQC licenses services if they meet essential standards and will constantly monitor whether they continue to do so. We formally review services when we receive information that is of concern and as a result decide we need to check whether a service is still meeting one or more of the essential standards. We also formally review them at least every two years to check whether a service is meeting all of the essential standards in each of their locations. Our reviews include checking all available information and intelligence we hold about a provider. We may seek further information by contacting people who use services, public representative groups and organisations such as other regulators. We may also ask for further information from the provider and carry out a visit with direct observations of care. Where we judge that providers are not meeting essential standards, we may set compliance actions or take enforcement action: Compliance actions: These are actions a provider must take so that they achieve compliance with the essential standards. We ask them to send us a report that says what they will do to make sure they comply. We monitor the implementation of action plans in these reports and, if necessary, take further action to make sure that essential standards are met. Enforcement action: These are actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers are set out in the law and mean that we can take swift, targeted action where services are failing people. Page 15 of 16

16 Information for the reader Document purpose Author Audience Further copies from Copyright Review of compliance report Care Quality Commission The general public / Copyright (2010) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Quality Commission Website Telephone address Postal address enquiries@cqc.org.uk Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Page 16 of 16