DOMICILIARY CARE AGENCY Barclay Gardens DCA Wellington Road Donnington TELFORD Shropshire TF2 8AB Lead Inspector Karen Powell Key Announced Inspection 9th November 2006 09:30 Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 1
The Commission for Social Care Inspection aims to: Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Inspection Report Author CSCI Audience General Public Further copies from 0870 240 7535 (telephone order line) Copyright This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Internet address www.csci.org.uk Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 2
This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this agency are those for Domiciliary Care. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 3
SERVICE INFORMATION Name of service Barclay Gardens DCA Address Wellington Road Donnington TELFORD Shropshire TF2 8AB Telephone number 01952 606645 Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration www.coveragecareservices.co.uk Coverage Care Services Ltd Ms Patricia Ann Owen Domiciliary Care Agencies Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 4
SERVICE INFORMATION Conditions of registration: 1. That Coverage Care (Shropshire) Limited is registered to provide domiciliary care services to older people, including people with dementia. Date of last inspection 9th August 2005 Brief Description of the Service: Barclay Gardens is a registered domiciliary care agency situated on Wellington Road, Donnington, Telford. The Registered Manager is Patricia Owen. MS Owen has many years experience of working in the care sector. The agency caters for both male and female service users and is based within Barclay Gardens a newly built complex that is also registered with the Commission for Social Care Inspection as a care home and regulated independently of the domiciliary care agency. There are 24 self-contained flats at the scheme, that are managed by Bromford Housing Trust. The care service within the scheme is managed Coverage care. Tenants have the opportunity to access restaurant facilities on a daily basis if they so wish. The agency also provides domiciliary care to the wider community and there are a number of service users in receipt of community care packages. The agency provide personal care, assistance with meals, shopping and laundry for service users who by reason of illness, infirmity or disability are unable to provide this for themselves without assistance. The range of fee s are dependant upon the number of hours provided and if the service user is privately funded or assisted by the local funding authority towards the cost of their care. Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 5
SUMMARY This is an overview of what the inspector found during the inspection. The inspection was a key announced inspection and started at 9.30am and lasted 7 and a quarter hours. One inspector carried out the visit. All 11 key National Minimum Standards for domiciliary care were assessed and a quality rating provided based on each outcome area for service users. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. The inspection included visits to service users in their own homes on the day of the inspection. Discussions were held with the manager, deputy and three members of the care team during the inspection. Written comments and feedback via questionnaires were sought prior to the inspection from a number of individuals. These included: Service users, staff and Health and Social care professionals. Completion of a pre inspection questionnaire by the agency formed part of the pre inspection work. What the service does well: Service user feedback has been positive in relation to the quality of care individuals are in receipt of. Comments included They are all very good to me and look after me well. There is a clear assessment procedure in place where all service users are assessed prior to a service commencing. Risk assessments are undertaken where necessary and safe systems of work implemented for staff to follow. A well trained staff group who are regularly supervised and appraised provides care. Recruitment procedures are robust which include appropriate pre employment checks making sure that service users are protected at all times. Complaints are dealt with appropriately in line with the complaints policy. What has improved since the last inspection? There has been an appointment of a deputy manager who has almost completed NVQ 4 training. The deputy is a care ambassador for Shropshire Partners In Care. It is intended that she undertakes her Registered Managers award in the near future. Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 6
An administrative assistant has also been appointed since the last inspection visit. The organisation have provided training in the following subjects; medication, bereavement, dementia and diabetes awareness. What they could do better: The Registered Manager must follow Multi Agency Adult Protection procedures in a consistent way and report under regulation all allegations of abuse to the Commission for Social Care Inspection. A training needs analysis must be completed for all staff members, which will identify any specialist training required to meet the needs of service users the agency provides care to. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 7
DETAILS OF INSPECTOR FINDINGS CONTENTS User Focused Services (Standards 1 6) Personal Care (Standards 7-10) Protection (Standards 11-16) Managers and Staff (Standards 17-21) Organisation and Running of the business (Standards 22-27) Scoring of Outcomes Statutory Requirements Identified During the Inspection Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 8
User Focused Services The intended outcomes for Standards 1 6 are: 1. Current and potential service users and their relatives have access to comprehensive information, so that they can make informed decisions on whether the agency is able to meet their specific care needs. 2. The care needs requirements of service users and their personal or family carers when appropriate, are individually assessed before they are offered a personal domiciliary care service. 3. Service users, their relatives and representatives know that the agency providing their care service has the skills and competence required to meet their care needs. 4. Each service user has a written individual service contract or equivalent for the provision of care, with the agency, except employment agencies solely introducing workers. 5. Service users and their relatives or representatives know that their personal information is handled appropriately and that their personal confidences are respected. In the case of standards 5.2 and 5.3, these do not apply to employment agencies solely introducing workers. 6. Service users receive a flexible, consistent and reliable personal care service. In the case of standards 6.3 and 6.4 these do not apply to employment agencies solely introducing workers. The Commission considers Standard 2 the key standard to be inspected. JUDGEMENT we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care needs of individuals are assessed by a suitably qualified person before a domiciliary service is commenced EVIDENCE: The inspector spoke to one new service user who has recently moved into the complex. They told the inspector that they had been assessed prior to moving into the home. Through discuss with the individual it was apparent that the family were also involved in the assessment process. Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 9
Examination of assessment documentation confirmed that the assessment was undertaken by the deputy manager prior to the service commencing. Service users funded by the local authority are fully assessed by a social worker. Documentation provided from social services was also seen during examination of service user records. Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 10
Personal Care The intended outcomes for Standard 7 10 are: 7. The care needs, wishes, preferences and personal goals for each individual service user are recorded in their personal service user plan, except for employment agencies solely introducing workers. 8. Service users feel that they are treated with respect and valued as a person, and their right to privacy is upheld. 9. Service users are assisted to make their own decisions and control their own lives and are supported in maintaining their independence. 10. The agency s policy and procedures on medication and health related activities protect service users and assists them to maintain responsibility for their own medication and to remain in their own home, even if they are unable to administer their medication themselves. In the case of standards 10.8 and 10.9, these do not apply to employment agencies solely introducing workers. The Commission considers Standards 8 and 10 the key standards to be inspected. JUDGEMENT we looked at outcomes for the following standard(s): 8 & 10 The principles of privacy, dignity and respect are put into practise by the care staff team. Policies, procedures and training are in place for the handling of service user medication. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Six service user comment cards were returned as part of the pre inspection work and in addition, those service users spoken to on the day of the inspection all confirmed that staff deliver their personal care in a sensitive and dignified manner. During discussions with the staff team it was clear that they Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 11
strive to provide a high standard of care respecting the values of privacy and dignity when delivering direct care to individuals. There is a clear policy and procedure in place for dealing with service user medication. During discussion with staff the inspector was told that they had all completed medication training. This was confirmed during examination of staff training files where certificates were seen to confirm this. Examination of one service user who has assistance with medication was seen to be satisfactory. Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 12
Protection The intended outcomes for Standards 11-16 are: 11. The health, safety and welfare of service users and care and support staff is promoted and protected, except for employment agencies solely introducing workers. 12. The risk of accidents and harm happening to Service Users and staff in the provision of the personal care, is minimised, except for employment agencies solely introducing workers. 13. The money and property of service users is protected at all times whilst providing the care service, except for employment agencies solely introducing workers. 14. Service users are protected from abuse, neglect and self-harm, except for employment agencies solely introducing workers. 15. Service users are protected and are safe in their home, except for employment agencies solely introducing workers. 16. The health, rights and best interests of service users are safeguarded by maintaining a record of key events and activities undertaken in the home in relation to the provision of personal care, except for employment agencies solely introducing workers. The Commission considers Standards 11, 12 and 14 the key standards to be inspected at least once. JUDGEMENT we looked at outcomes for the following standard(s): 11, 12 & 14 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Health and safety policies procedures, provision of risk assessments and training protect both service users and staff when attending to service user needs. Adult protection procedures are in place, however they have not been consistently followed in all cases. Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 13
EVIDENCE: Health, safety and welfare of service users and staff are promoted through a comprehensive range of policies and procedures, staff training and safe systems of work being implemented following risk assessments being undertaken. Discussion with staff and examination of training files confirmed that all staff undertake health and safety training during induction training. Training in food hygiene and infection control is also undertaken by care staff. Examination of three service user files confirmed that risk assessments are undertaken where applicable. It was stated on the pre inspection questionnaire completed by the manager that one referral to adult protection had been made since the last inspection. This had been appropriately dealt with and notified to the Commission for Social Care Inspection. Prior to this inspection being undertaken the Commission for Social Care were contacted by a concerned relative that an allegation of abuse had been reported to the manager and had not been appropriately investigated. During the inspection this incident was discussed with the manager and records examined. An investigation by the registered manger was requested by the police and this was duly completed. The outcome of that investigation was fed back to the police as requested. It was established that although the allegation had been directly reported to the police by the service user and referred to the manager on the day the incident it had not been reported to the adult protection team by the registered manager. The matter had also failed to be reported to the Commission for Social Care under regulation. All allegations of potential abuse must be reported to the adult protection team and notification to the Commission for Social Care Inspection must be made not later than 24 hours where the registered manager has reported the matter to the police or is informed that the matter has been reported to the police. Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 14
Managers and Staff The intended outcomes for Standards 17-21 are: 17. The well-being, health and security of services users is protected by the agency s policies and procedures on recruitment and selection of staff. 18. Service users benefit from clarity of staff roles and responsibilities, except for employment agencies solely introducing workers. 19. Service users know that staff are appropriately trained to meet their personal care needs, except for employment agencies solely introducing workers. 20. The personal care of service users is provided by qualified and competent staff, except for employment agencies solely introducing workers. 21. Service users know and benefit from having staff who are supervised and whose performance is appraised regularly, except for employment agencies solely introducing workers. The Commission considers Standards 17, 19 and 21 the key standards to be inspected. JUDGEMENT we looked at outcomes for the following standard(s): 17, 19 & 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment procedures are robust which ensure that service users are protected. Staff are supported to undertake training relevant to their role and responsibilities. The agencies commitment to the NVQ training programme continues to benefit service users who are supported by well-trained and qualified staff. All staff receive supervision on a regular basis. EVIDENCE: Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 15
Five staff personnel records were seen, three were long serving employees, two were records of new starters. Records of new starters were well organised and contained all of the information required by Schedule 3 of the Domiciliary Care Regulations 2002. All of the necessary pre employment checks and references had been received prior to employment commencing. Coverage Care supports all staff to undertake training in relation to their role. It was stated on the pre inspection questionnaire completed by the manager as part of the pre inspection work that there are 15 staff who have achieved NVQ training and a further eight who are undertaking NVQ training. Staff interviewed by the inspector told her that training opportunities are good and that mandatory training is updated on a regular basis. An overall record of training undertaken is maintained by head office and regularly updated. The system has the capacity to flag up when updates are required. The November spreadsheet was shared with the inspector which, confirmed training that care staff had told the inspector they had attended. This also corresponded with a sample of certificates examined at the inspection. Currently individual training analyses are not produced at the end of induction training and reviewed through supervision when discussing with care staff service user needs. It was established through examination of assessments and care plans that there are some gaps in staff training relating to individual specialists needs. These included stroke awareness training and multiple sclerosis awareness/training. This was discussed with the manager and action was taken during the inspection to source relevant training for those staff concerned. Staff interviewed confirmed they all receive regular supervision. Examination of staff files confirmed this. Annual appraisals are also undertaken and again records of these were seen on individual staff files. Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 16
Organisation and Running of the Business The intended outcomes for Standards 22 27 are: 22. Service users receive a consistent, well managed and planned service. 23. The continuity of the service provided to service users is safeguarded by the accounting and financial procedures of the agency. 24. The rights and best interests of service users are safeguarded by the agency keeping accurate and up-to-date records. 25. The service user s rights, health, and best interests are safeguarded by robust policies and procedures which are consistently implemented and constantly monitored by the agency. 26. Service users and their relatives or representatives are confident that their complaints will be listened to, taken seriously and acted upon. 27. The service is run in the best interests of its service users. The Commission considers Standards 22 and 26 the key standards to be inspected at least once. JUDGEMENT we looked at outcomes for the following standard(s): 22 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises are suitable for the purpose of running a domiciliary agency. Complaints are taken seriously and acted upon in an appropriate way in line with the agency s complaints policy and procedure. EVIDENCE: Barclay Gardens is purpose built and is fully equipped with a main office and separate administration office. The office is manned between the hours of 9.00am to 5.00pm with an on call system operating to cover out of hours. A concierge service is available for the tenants of the building. There are clear lines of accountability within the agency. Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 17
The pre inspection questionnaire completed as part of the pre inspection research declared seven complaints had been received at the agency since the last inspection. Records of these were seen to be kept in a central complaints file. Records of complaints were detailed and included details of the complaint, investigation and outcome. All had been responded to in line within the agencies complaints procedure. Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 18
SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Domiciliary Care have been met and uses the following scale. 4 Standard Exceeded (Commendable) 3 Standard Met (No Shortfalls) 2 Standard Almost Met (Minor Shortfalls) 1 Standard Not Met (Major Shortfalls) X in the standard met box denotes standard not assessed on this occasion N/A in the standard met box denotes standard not applicable User Focused Services Managers and Staff Standard No Score Standard No Score 1 x 17 3 2 3 18 x 3 x 19 2 4 x 20 x 5 x 21 3 6 x Personal Care Organisation And Running Of The Business Standard No Score Standard No Score 7 x 22 3 8 3 23 x 9 x 24 x 10 3 25 x Protection Standard No Score 11 3 12 3 13 x 14 2 15 x 16 x 26 x 27 3 Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 19
Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Domiciliary Care Regulations 2002 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 1 DO14 14 All allegations of abuse must be 09/12/06 (12)(b) reported to the adult protection team and the Commission for Social Care Inspection. 2 DO19 15(2)(a) Staff must be provided with 09/03/07 specialist training when circumstances require (see Appendix E to the Regulations/Standards) 3 DO19 15(2)(a) A training needs analysis reflecting the experience/qualifications of the individual member of staff and their anticipated workload must be undertaken on completion of induction. 09/03/07 Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 20
RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 21
Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Barclay Gardens DCA DS0000050865.V297005.R01.S.doc Version 5.2 Page 22