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Inspection on 28/01/09 for Dalwood Farm

Also see our care home review for Dalwood Farm for more information

This is the latest available inspection report for this service, carried out on 28th January 2009.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Not yet rated. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Dalwood Farm Dalwood Farm Dinton Salisbury Wiltshire SP3 5EY The quality rating for this care home is: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Roy Gregory Date: 2 8 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. They reflect the things that people have said are important to them: 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 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 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. Internet address www.cqc.org.uk Information about the care home Name of care home: Address: Dalwood Farm Dalwood Farm Dinton Salisbury Wiltshire SP3 5EY 01722717922 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): andynosko@aol.com Ability Associates Limited Name of registered manager (if applicable) Mr Andrew Nosko Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 2 1 0 0 care home 3 learning disability physical disability Additional conditions: No more than 2 male service users with a Learning Disability at any one time No more than one male service user with a Learning Disability AND a Physical Disability at any one time. Date of last inspection A bit about the care home The home is at the Western edge of the village of Dinton, about half an hours drive from Salisbury. The Registered Provider is Ability Associates Ltd and the Registered Manager is Mr Andrew Nosko. Mr Nosko also manages another small care home within the organisation. Dalwood Farm is an old farmhouse providing single room accommodation on both the ground and first floor. There is a small sitting room and a large spacious kitchen with a dining area. In addition to the farmhouse there are a number of outbuildings, large vegetable gardens, an orchard and adjoining fields. The farm also has a number of animals including Shetland ponies and chickens. Residents and staff maintain the environment and animals. Due to its rural, tranquil positioning, the home has company cars for journeys as required. Residents often receive one-to-one support during the day. At night two members of staff provide sleeping in provision. There is also an on call management system in place. The fees for the home are variable depending on the level of care required. At present, weekly fees are in the range of GBP1400 to 1500. 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: Choice of home Individual needs & Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct and Management of the Home Poor Adequate Good Excellent How we did our inspection: This is what the inspector did when they were at the care home We visited Dalwood Farm on Wednesday 28th January 2009, between 10:00 a.m. and 5:00 p.m. We met and talked with all three people that live at the home. They showed us their rooms and we looked round all the home and grounds. We were able to see how staff were organised and what people did during the day. We spent time talking to Andy Nosko, the manager, and also the deputy manager and other staff. We looked at records in the offices. These included peoples support plans and health records, and staff supervision records. We saw how the senior staff checked on health and safety, and cleaning standards. We had seen staff recruitment information when we inspected 77 The Street, which shares the staff team, but we looked again at training information. We had received some surveys from residents and members of staff, and the Annual Quality Assurance Assessment from Mr Nosko. What the care home does well People living in the home told us they could to do the things they wished to do, and opt out of things they didnt like. They liked the fact they were each treated as individuals. The guide to the home made it clear people were expected to help with tasks in the home and the farm area that goes with it. This meant people could work closely with animals and in the gardens. People belonged to clubs and went to the cinema and sports centres, so they had friends and did varied activities and sports. Staff put a lot of effort in helping people find the things they wanted to do. There were cars provided for staff to take people out into the towns and countryside. People had a lot of one-toone time with staff. We saw that food cupboards and the freezer were well stocked, and one of the people living at the home was checking them to help prepare the shopping list. People chose what they wanted to eat and had meals together with staff. Sometimes they went to a local pub with staff, and holidays were arranged each year. Staff had good links with the doctors surgery. They supported people to keep health appointments. They got advice from health workers, and also gave advice to hospitals about the best way to care for the people from the home. The house is old but feels like home. People keep their bedrooms how they like. They share a cosy sitting room and the kitchen and dining room, which are used as a centre for people to meet for hot drinks and meals. There were no fixed routines for cleaning and laundry. As one member of staff put it, its how you do it at home. We found the home to be very clean in all parts. Rotas showed that at least two staff were available to support residents all the time, including two staff members sleeping in at night. Residents knew who would be coming on duty to support them. The staff team has not changed much over time so the people that live at the home and the staff know each other well. One new member of staff had joined since our last inspection. We saw their background was checked properly before they started. Most staff had got NVQ certificates to show they had learned about different ways of supporting people. What has got better from the last inspection Some things had been added to care plans and risk assessments to make sure they included things that were missing at the last inspection. We also said at the last inspection that staff needed to update their training. Mr Nosko had taken a long time to organise this. Staff had received new training in first aid and food hygiene, but arrangements for their training in how to help people with difficult behaviour were only just being made. There were improvements to the daily notes that staff wrote about how people were, as recommended at the previous inspection. Mr Nosko said this was something he checked continuously. There were also better staff procedures in supporting how people got their money, if they had asked staff to look after it. People told us that if they asked for such support, they always knew how much money was being held, and could ask for it at any time. What the care home could do better Peoples plans helped staff know how to support them, but they could also be used to help people decide on things they would like to get better at. They could show what people are already good at, as well as what they find difficult. They could use pictures, especially photos, to demonstrate this, and to keep a record of what people did to try to reach their goals. Peoples plans and support guidelines were not always reviewed when they should be. People need to decide every so often if their support is working out how it should, and if there are other things they want to try. Staff know people well, so the home can have a review even if they cannot get everyone involved that they would like to. Staff sometimes have to hold someone to help them stop doing something that could hurt themselves or someone else. It is important for staff to know exactly how to do this, and how to try and stop difficult situations happening. Mr Nosko was arranging the training they need. We have said he must show us when the staff have been trained. The staff take a lot of responsibility for people, especially when they are out and about with no other staff. They need to have time with their senior staff to think about how they are supporting people, and what support they need to be able to do a good job. This is called supervision and it needs to be planned, to make sure staff get this support. The staff have not been getting enough supervision. If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact Roy Gregory 33 Greycoat Street London SW1P 2QF 02079792000 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 set out 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 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 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 . There is a detailed assessment and admission process to ensure any admission would be appropriate to the individual concerned. Evidence: The home provides long-term care for three people, so assessment for vacant places is a rare occurrence. We have been satisfied from previous inspections that the organisation has a detailed admission procedure. This involves receipt of a care managers assessment and a full assessment by the home of the prospective residents current needs, together with details of any previous placement. The process provides for consultation with the people with whom the person would be sharing the home. Admission would be followed by an early review, to check the placement was appropriate and to finalise agreement of support plans. 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 . Peoples assessed needs are reflected in care and support plans, but these do not incorporate personal goals for development and are not systematically reviewed. People are supported in making decisions about their everyday lives, but setting of longer-term goals could help give a sense of achievement and progress. Risks are identified, and assessed in such a way as to encourage safe participation in a range of activities. Evidence: In the office there were support plans for each of the people living at the home. They included support guidelines to explain to staff how to meet individual needs. As required at the previous inspection, they reflected the range of an individuals needs well, but there remained little acknowledgement of peoples strengths and abilities, from which aspirational goals might be developed. Goal-focussed plans would in turn enable key workers, and any staff writing daily records, to report on how their work with people was helping achieve goals, rather than merely confirming that basic planned care and support routines were being upheld. Daily recording by staff, however, was more objective, as recommended at the previous inspection. Mr Nosko said this was something he monitored continuously. Support guidelines each stated when they were to be reviewed, but there was not evidence in each case that this had been carried out. This was explained as a result of difficulty securing external care management support to the review process in all cases. However, the home has the expertise to carry out its own reviews, one outcome of which might be to continue to press for greater care management support, where this is found to be lacking. The people who lived in the home confirmed they were aware of their support plans Evidence: and the keeping of daily records. One plan stated it had been explained to and agreed by the resident, and their care manager had signed to show their participation in this. Another persons plan was signed by them and by a duty social worker, whilst the third showed no evidence of agreement. Our recommendation at the previous inspection, to ensure care plans are more person-centred, needed further attention. There was evidence the home had obtained some advice about increasing the pictorial content of support plans, to aid residents direct participation and understanding, but staff did not find that the advice they had received fitted with the particular needs of the current residents. However, it was agreed during the inspection that use of photographs rather than line drawings might well offer an appropriate way forward. Residents could participate directly in taking and choosing photographs. A behaviour management plan was in place for one resident, drawn up by a learning disability nurse. Notifications of the occasional incidents that had arisen in the home, and talking with staff, confirmed that the agreed responses to behavioural issues were carried out. However, the nurse had stipulated that the plan must be evaluated by a certain date, which was now long passed. Staff noted in incident reports that the persons more recent behaviours might be affected by a particular health concern. So they showed there was competence within the home to carry out an evaluation, which might lead to some adjustment to the management plan, or further referral to an outside professional. For another person there was a strategy for aggressive or difficult behaviour. The guidelines for intervention were written in positive terms, but it would be helpful to identify the actual nature of behaviours the person was known to present, and whether they had been recognised as indicating what the person might be trying to communicate. It would then be possible, in recording a specific incident, to assess whether it fitted the persons recognised patterns, or if there were any change in presentation or in their response to intervention. People living in the home told us they were able to do the things they wished to do. They appeared to appreciate having basic routines, and certainly liked the fact they were each treated as individuals. Decisions to join in or decline activities were respected. People showed some understanding of staff roles in responding to difficult behaviour issues, which they saw as maintaining a safe and comfortable environment. However, the delays in reviews of support plans, and the fact the plans were not clearly centred on aspirational goals, limit the extent to which the home can demonstrate that people are assisted to make decisions that affect their lives. Risk assessments were in place within the residents care plans. Residents were assisted to take appropriate risks on a day-to-day basis. Issues addressed included tasks within the home, such as making drinks and using garden machinery, and activities outside, such as swimming. 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 . Varied activities give people access to the community and opportunities to maintain leisure interests. Relationships with families and friends are encouraged. People participate in everyday tasks and their rights are respected. A healthy diet is offered, and mealtimes are conducted as people want. Evidence: The service user guide was explicit in setting out the basic routines of the home and farm environment that people were expected to participate in. Things in the home generally, and in peoples bedrooms, reflected the age, gender and interests of the people living there. The organisation of everyday life provided a balance between household routines, involvement with the animals and gardens, personal enjoyment of time and accessing the community. People told us about their various activities. They regularly took part in sports of their choice, such as bowling, swimming and horse riding. One person had been to the cinema the previous evening. They went to a day resource in Salisbury. People had audio-visual equipment in their bedrooms. They visited a local pub, with staff support. All staff that responded to our survey identified provision and facilitation of activities as a strength of the service. Staffing of the home was sufficient such that people could be given a lot of one-to-one support to pursue their interests, or to opt out of any particular activity if they chose. One member of staff wrote that the service trawls services that are available to meet identified needs, i.e. college, sheltered employment trusts, sports centres, etc. The provider company had a number of vehicles that were Evidence: used for arranged and spontaneous trips into the local community, and further afield. For holidays, arrangements were made for people to stay at holiday centres, in groupings of their choice and with staff support. One person was assisted to maintain a close relationship with someone in a town some miles away. There was support to maintaining contacts with peoples families. Use was made of clubs in the area. Records provided good evidence of how people were supported to remain active and in touch with other people. Individual staff strengths were utilised effectively. People in the home confirmed they had a choice of menu, and records showed they often made separate choices for the same meal. We saw that food cupboards and the freezer were well stocked, and one of the people living at the home was checking them to help prepare the shopping list. Two residents helped with this task, whereas the third confirmed he disliked shopping and took no part in it. People were seen to get hot drinks when they wanted them, but cooking of meals was a staff task. Given how residents awaited the evening meal with anticipation, it is probable one or more could respond to a more direct part in cooking. This illustrates the lack of developmental planning within support plans, as noted in the previous section of this report. People did assist with other tasks related to meal times, such as washing up, and it was clear that people derived satisfaction from their contribution to maintenance of the smallholding aspects of the home. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service . The home provides personal support in line with peoples preferences and needs. There are good links and systems to ensure physical and emotional health needs are met. People are generally protected by the homes medication procedures, but the use of as needed medicines is not always adequately explained. Evidence: People living at the home did not require direct support to personal care. They confirmed they washed and bathed when they wished, and wore what they chose, whilst staff gave background prompting where necessary. Health care needs were described appropriately in support plans, and appointments were tracked and monitored. For one person who had attended hospital for a procedure, the home had been proactive in advising health professionals about how to work with the person, to allay anxieties. For another person, the homes records of observations were clearly helpful in demonstrating the cyclical nature of a medical matter. This evidence in turn had been used to agree a protocol for the use of a medicine prescribed for use as needed. The staff received training in first aid. Mr Nosko incorporated epilepsy and diabetes awareness in this training. To ensure such training is up to date, and relevant to the individual residents concerned, it would be worth requesting re-assessments of conditions from specialist nurses. Medications were not used to a great extent in the home. We saw that there was a positive relationship with the GP surgery and that the home would request medication reviews. There were good arrangements for the storage and administration of medications. There was evidence that unused and discontinued medicines were returned periodically to the pharmacy, something that was necessary at the time of our visit. Support workers were trained in using the monitored dosage system in which Evidence: most medicines were dispensed, whilst the deputy manager had been trained to a higher level in handling medication, and took a lead on this in the service. Medication Administration Record (MAR) charts were well kept. However, there was inconsistency in recording of use of as needed medicines. Their use was always shown on the MAR chart, but there should uniformly be a brief explanation of the circumstances of each usage on the reverse of the chart, which in turn must always cross-reference to an entry in the persons daily record of care given. 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 . There are appropriate policies to protect people from harm, subject to staff being retrained in safe use of breakaway techniques. The service has procedures to receive and act on complaints. Minor shortfalls in quality of provision are addressed within day-to-day management, but may not be recorded in such a way as to be used to improve overall provision. Evidence: No complaints had been recorded within the service since the previous inspection. Complaints forms kept with peoples support plans could be asked for at any time and completed in order to bring a complaint within the scope of the company complaint procedure. Information for people living in the home, and their supporters, included details of the provision for addressing complaints, and how to contact CSCI. We observed that people had good relationships generally with all staff, and strong relationships with particular staff, including a lot of one-to-one support. Combined with the nature of everyday life in the home, with shared tasks and meal breaks and plentiful conversation, residents had opportunities to voice concerns in such a way that use of the formal complaint route is likely to be circumvented in most cases. However, the manager and staff should be mindful of the need to record and therefore monitor minor issues of dissatisfaction and how they are addressed, in order to identify any patterns, and to be satisfied that quality of service delivery is being maintained. Staff received abuse awareness training from Andy Nosko. Staff were issued with the No Secrets abbreviated guide to local inter-agency safeguarding procedures, and there was a copy in the office. Historically the service has worked co-operatively with the procedures. Further to a recommendation from the previous inspection, staff procedures in supporting peoples access to personal monies had been improved. As before, management undertook regular checks on actual balances held. Residents told us that if they asked for such support, they always knew how much money was being held, and could access it at any time. Staff and residents described staff use of physical intervention to manage particular Evidence: behavioural incidents. Records of such incidents were sufficient to show why the intervention was used, and that it was used in accordance with individual behaviour management plans, for very short duration, where alternative interventions were unsuccessful. However, staff training records showed that many staff had not received updating training in this area of practice for a considerable time. Mr Nosko said the accreditation of prospective trainers was being checked at the time of our visit, with the intention of retraining the entire staff group in the near future. 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 . Dalwood Farm provides a homely and stimulating environment, maintained and kept clean to a good standard. Individual bedrooms reflect peoples needs and lifestyles. Evidence: The property has inevitable problems associated with its age, for example damp around some window frames, but it was said that the National Trust, as landlord, was quick to rectify identified issues. The house had plain but clean decor throughout. Residents had single bedrooms, without the benefit of wash hand basins. There was a bathroom and toilet upstairs and further toilet downstairs. A room downstairs doubled as office and staff sleep-in room, whilst upstairs were a sleep-in room and separate administrative office. Residents shared space comprised a small sitting room, and kitchen/dining room, off which was a further general-purpose room that was used in part as a smoking facility. A utility room housed a washing machine, tumble drier, freezer and cleaning tools. Outside, the home had various outbuildings including stables, a paddock, orchard, lawn areas and vegetable gardens. It was not adjacent to any other residential property. Residents assisted with cleaning tasks around the home. Usually one person would help with these tasks whilst two others were out. Paper towels had been assessed as inappropriate to be used in the toilets. Instead, cloth towels were changed twice daily. Personal toiletries were not left in the bathroom, in order to avoid shared use. There were no fixed routines for cleaning and laundry. As one member of staff put it, its how you do it at home. A resident confirmed he liked to keep his room clean, and a member of staff assisted him to dust and tidy. The manager and deputy manager monitored cleaning standards around the home. We found the home to be very clean in all parts. 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 supported by mostly qualified staff, and recruitment practices ensure people are protected from being cared for by unsuitable staff. Members of staff do not experience regular formal supervision and the employers commitment to staff development has been insufficient to ensure maintenance of safe care practices. Evidence: Rotas showed that at least two staff were available to support residents all the time, including two staff members sleeping in at night. Mr Nosko said that staff were very rarely called out at night, but when they were, they benefited from working as a pair. They also provided back-up to a sole sleeping-in staff member at another home run by the company. In our survey, staff regarded staffing levels as good, as they permitted a great deal of individual one-to-one support to be given. The home has had a stable staff team for some time, so there are strong relationships between the people that live at the home and those that support them. An additional staff member was recruited in the past year in order to add flexibility to shift rotas. Recruitment records for that person showed that all necessary checks were undertaken before confirming appointment. People using the service were not directly involved in the recruitment or selection process, but opportunities were created for candidates to be observed with residents. A benefit of low staff turnover is that most staff have attained National Vocational Qualifications (NVQ) in care, to level 2 or 3. Staff maintain skills and awareness by revisiting mandatory and other training. Train to Gain was used as a training resource. A training spreadsheet showed there was ongoing availability of training, which several staff mentioned in surveys as a particular strength of the service. However, we identified that a number of staff were out of date with aspects of their training, significantly so in working with behaviours that may challenge. Some had not updated this aspect of their training since 2003. This shortfall led to a requirement at the previous inspection, which has not been met. Mr Nosko agreed this was a priority Evidence: area for training, as the home provides a service that includes working with variable behaviours (see the Complaints and Protection section of this report). Mr Nosko takes responsibility for most training for the staff group and had latterly been concentrating efforts on food hygiene and first aid updates, as also required at the previous inspection. Two of the staff team were designated respectively as deputy manager, and senior support worker. These two people worked mostly on opposite shifts, to maximise their availability to staff and residents. They were booked to undertake risk assessment training. In their absence, one person on shift was designated shift leader. Most members of staff had recently received one-to-one supervision, mainly from the deputy manager. Supervision recording was good, but showed gaps of four to six months between meetings. Given the needs of vulnerable people being supported, and the level of responsibility and lone working expected of staff, this is insufficient. Both supervision, and annual appraisals, were lacking in forward planning. Some members of staff, and the manager, spoke of spontaneous in-depth discussions about work with the residents. Decisions and suggestions coming from this process should be recorded with supervision notes, but should not be regarded as a substitute for planned formal supervision. 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 . The registered manager has not demonstrated consistent leadership to the staff team. Provision for evaluating the quality of service provision is under-developed. There are systems in place to identify and promote the health and safety needs of residents and staff. Evidence: Andy Nosko is the registered manager of Dalwood Farm, and also of 77 The Street, a satellite home provided by the company. He has obtained the NVQ in care to level 4, as has the deputy manager, and also the Registered Managers Award. He shared the upstairs office with his brother, who is company secretary. Both offices at the home were well organised and had clear guidance to staff about routine duties and responses to events. Management and senior staff carried out monitoring checks on staff standards of work and recording. Staff meetings occurred approximately three-monthly. A member of staff commented in a survey return that they would like more frequent meetings, but they were difficult to organise due to the high levels of support and different activities carried out with the residents. In answer to what could the service do better? one member of staff wrote, have more team-building activities with the registered manager included. Andy Nosko had recognised this as an issue for himself. In response, he was not only increasing attention to the training plan, which was his area of responsibility, but also working some shifts on the staff rota. For quality assurance, feedback forms were used to obtain the views of relatives and professionals who are involved with people that live at the home. There was also a client validation form, for residents to give formalised feedback. Most people benefit Evidence: from support to complete such forms. Therefore it would be preferable for such assistance to be obtained from outside the organisation, for example from care managers or college tutors, to show they were completed independently of the provider company. An annual report should be produced, to give feedback to contributors and staff on the nature of responses obtained, and how the company intends to respond to the findings. Mr Nosko supplied us with an AQAA (Annual Quality Assurance Assessment) when asked to do so. However, this was poorly developed. It gave little evidence of a service actively seeking to improve. The AQAA should draw on the homes quality assurance system, demonstrating consultation with people using the service, and their representatives. We will expect the next requested AQAA to do so. Health and safety of residents and staff were well provided for by way of reviewed risk assessments, some of which had been improved in response to a requirement made at the previous inspection. There was evidence of regular training in fire procedures, including drills, and checks on related equipment. Are there any outstanding requirements from the last inspection? Yes  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 35 18(1)(a) The registered person must 30/04/2008 ensure that all staff are up to date with their training such first aid, food hygiene and the management of challenging behaviour. 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 Description 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 Description Timescale for action 1 6 15 The registered person must 29/05/2009 keep service users plans under review at planned timescales, or more frequently in response to significant changes, involving as far as possible all relevant parties as agreed with service users. There is a risk that practice may become routinised and out of step with changes, if the home does not confirm its professional role towards people in its care by ensuring plans are current. 2 20 13 The registered person must ensure every administration of medicines prescribed for use as needed is explained on the reverse of the Medicines Administration Record chart, which must in turn cross-refer to an entry in the daily record of care that explains why the 29/05/2009 medicine was necessary. It must always be clear that as neeeded medicines have been used as agreed with the prescribing doctor, service user and other interested parties. 3 23 13 The registered person must supply the Commission with evidence that all staff have received accredited training in breakaway techniques. 29/05/2009 Both residents and staff are vulnerable in situations assessed as needing physical intervention. Both must be confident of the knowledge and competence of staff members assessing situations and carrying out physical interventions. 4 36 18 All staff must receive formal, 29/05/2009 planned individual or small group supervision every two months. Members of staff need feedback on the effectiveness of their work with the people supported by the home. 5 39 24 The registered person must establish and maintain a system for evaluating the quality of the services provided at the care home, which: provides for consultation with service users and their representatives; results in production of an annual service development report; 29/05/2009 and informs content of the Annual Quality Assurance Assessment requested by the Commission. The service needs to demonstrate that it is responsive to the views and changing needs of all stakeholders, in order to maintain person-centred practice. A report to be produced during 2009, with firm plans for the process to be in place by the date shown. 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 The registered person should make sure personal plans show a balance of peoples abilities and needs; people should be enabled to set aims that lend themselves to evaluation, and recognition of achievements. The registered person should continue to explore ways of increasing peoples direct participation in support planning by means of pictorial aids, such as digital photography. The registered person should ensure that the actual nature of aggressive or difficult behaviour is described in intervention plans, so staff can assess and record whether presented behaviours are typical or variable. The registered person should seek re-assessments of individual medical conditions, such as epilepsy, from specialist nurses, where these have not been carried out for a significant period. The outcome of re-assessments should be incorporated as appropriate into health and first aid training provided to staff. The registered person should consider how to keep a record of minor issues of dissatisfaction and how they are resolved, to assist annual review of quality of service provision. 2 6 3 6 4 19 5 22 6 7 36 39 Instances of informal supervision should be recorded in the supervision records of individual members of staff. The registered person should identify people outside the service who can support individuals living in the home to give feedback to the company, and to the inspection process, by way of questionnaires or other means. Helpline: Telephone: 03000 616161 or Textphone : or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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