Quality & Care team was delivered, this included training in dignity and care. However, staff turnover has made it more difficult to fully integrate this into practice, across the board. 4th paragraph – The statement that ‘’the home is in a state of disrepair ‘’ is inaccurate and unjustified. There is a repair programme for the house compiled on the basis of staff reports and the maintenance team’s inspections. Repairs are prioritised on this basis. In terms of the specific points you have raised we would comment as follows: residents individual rooms are redecorated every three years on a rolling programme basis and the communal areas are re-decorated regularly and all the areas have been decorated between 2012 and 2014; since the last inspection a housing officer has visited Sistine and has stated there is only a minute patch of damp under one window that does not require treatment; there are five bathrooms all refurbished between October 2011 and July 2012 which are cleaned regularly; in one of these one tile was cracked having been kicked by a resident just prior to the inspection; the disused radiator pipes mentioned did not cause a hazard to the resident but we have had them capped and taken out ; in terms of signage all fire exit routes are clearly labelled ; no doors are blocked off except for a door to the basement which is locked for safety reasons – some other doors have automatic release mechanisms as approved by the Fire Officer . 4th paragraph: Fire safety: fire drills involving all staff on duty are undertaken on a minimum 6 monthly basis, the most recent being in March 2015. If in doubt there is an individual action plan for staff to refer to. To increase awareness X people using the service. Now reads “We found some aspects of the home were poorly maintained. We found disused pipes sticking out of one person’s floor, bathrooms which were unclean and in disrepair, and evidence of damp in people’s rooms. The homes layout was not suitable for the needs of people with complex needs. The home was set out over three floors. We had concerns around fire safety as staff were unable to satisfactorily explain how they would support people in the event of a fire.” – This is what was observed on the inspection including the strong smell of damp in a downstairs bedroom which was raised immediately. Not a factual accuracy comment.
amongst staff we will arrange for monthly fire drills to take place over the next 6 months and on a three monthly basis, thereafter. 7th paragraph – Mental Capacity Act: The funding authorities were involved in the decision making process for each resident. D.O.L.S. authorisations are either in place or pending in the case of each resident. The issue of restraint is covered in the D.O.L.S guidelines. We would ask that the inspectors clarify their specific concerns in this regard. X X Correct. But was no evidence that REACH had raised this with the LA. This has been explained in the report. “This was evidence that understanding of the term ‘restraint’ within the service was poor. We saw where people were deprived of their liberty; restraint was constantly used in the form of one to one care, using restraint to prevent people entering rooms and guiding people into different rooms.” Page 4 Summary of findings – Is the service safe? Is the service caring? ‘’ high use of agency staff ‘’. The actual vacancy rate at the time of the inspection was 6 out of a total of 27 posts excluding the manager [ 22%]. The use of agency was lower than this because permanent staff are able to provide cover through overtime. Also to achieve better continuity of care we draw agency workers from a regular pool of staff. We would wish to query how the C.Q.C. would define high levels of agency staff. ‘’ were no arrangements in place to ensure people were supported in an appropriate and person centred manner.’’ This is a sweeping statement that is not justified given references X Now reads “Staffing levels were inadequate with use of agency staff to cover shifts.” This is referred too throughout the whole report.
elsewhere in the inspection report to positive practice, e.g. page 10: ‘’ During our second day, lunch appeared to be less rushed and more person centred.’’ The first three findings use the term ‘’ not always caring ‘’. However, on page 10 paragraph 3, staff are described as being ‘’ mostly caring in their approach to people’’. These statements should be made consistent by using the term ‘ mostly caring ‘ in the text on page 4. The home has received the ‘smile for life’ accreditation for oral health care through Bucks CC Smile for life campaign in recognition of supporting people to a high standard in this area. REACH are the only organisation in Bucks were have all homes received this accreditation. X Amended. Not a factual accuracy comment and evidence was not provided on the inspection. Page 5 Background to this inspection 4th Paragraph – ‘Before the inspection we asked the provider to complete a PIR. We did not receive a completed PIR form from the provider’. As stated on page 13, last paragraph, it was reported that this form was not received by the provider. This to be reflected in the statement on page 5. In addition the provider did complete a Residential Services Contact List via email on 13.11.14 and this was completed and returned on 14.11.14. Evidence of which was emailed to the lead inspector on 30.04.15. Now reads “We did not receive a completed PIR form from the provider as the inspector was advised that the request had not been received.” Page 5 Background to this inspection 5th Paragraph – 2nd sentence Change ‘Interim Manager’ to ‘Homes Manager’ and change ‘Operations Director’ to ‘Operations Manager’. Amended. Page 6 Is the service safe? 3rd Paragraph – 4th sentence Change ‘Interim Manager’ to ‘Homes Manager’. Amended. Page 6 Is the service safe? 3rd Paragraph – 5th sentence ‘For the whole of April the rota showed there was only one day where they met these minimum staff numbers. On six occasions staffing numbers were less than 3 on either an early or late shift. It was not recorded if agency staff were used to make up minimum numbers’. X This evidence was not provided at the inspection when requested.
Sistine always has a minimum of 8 staff per shift when a capacity of 15 service users are present. The rota’s provided did not contain an accurate picture of staffing used on each day in April, which included agency staff, this was an administrative shortfall. Evidence of all staff working on each shift is recorded and available to view in the homes 24 hour handover book therefore the home has been staffed appropriately and staffing levels have not been unsafe. Page 6 Is the service safe? 5th Paragraph – 2nd sentence. ‘a lot of risk assessments were not dated or were missing.’ All risk assessments have a date of implementation and a review date present. The guideline documents only have implementation dates and no review dates entered so the documents being referred to in this sentence need to be changed to ‘guidelines’ instead of risk assessments. Both guidelines and risk assessments were found to be out of date and/or missing. Page 8 Is the service effective? Paragraph 1 ‘’ we found no improvement had been made to the provision of supporting staff development through induction, training and supervision.’’ This statement is not consistent with the facts. A copy of the R.E.A,C.H. training matrix was forwarded to the C.Q.C. which identifies the additional training provided to staff. Generally, positive efforts have been made to increase the provision and the quality of training to staff; however the impact of this on practice of this has been adversely affected by staff turnover. Paragraph 5 states that no formal induction is received by agency staff. An induction folder is available to agency staff and a brief induction process is used for them. Paragraph 2 refers to the need for Makaton training; Makaton communication materials are being provided to staff. X X X Training had been provided, however this had had little or no impact on the way staff competency or ability during discussions and observations. This was confirmed by agency we spoke with. We saw no evidence that these communication materials were
Page 13 Is the service well led? 2nd Paragraph – 8th sentence. Change ‘Interim Manager’ to ‘Homes Manager’. Amended. Page 13 Is the service well led? 5th Paragraph – 1st sentence. Change ‘Operations Director’ to ‘Operations Manager’. Amended Page 13 Is the service well led? Last Paragraph. Change ‘Interim Manager’ to ‘Homes Manager’ and change ‘Operations Director’ to ‘Operations Manager’. Amended. (Include additional rows if required) Completed by (name(s)) Abbas Shams Position(s) R.E.A.C.H. Managing Director Date 09.06.15