Inspection on 25/04/07 for 1, 3, 5, 7 Exmoor Drive

This inspection was carried out on 25th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1, 3, 5, 7 Exmoor Drive 07/05/09

1, 3, 5, 7 Exmoor Drive 11/05/06

1, 3, 5, 7 Exmoor Drive 27/10/05

1, 3, 5, 7 Exmoor Drive 23/06/05

1, 3, 5, 7 Exmoor Drive 03/03/05

1, 3, 5, 7 Exmoor Drive 15/09/04

1, 3, 5, 7 Exmoor Drive 18/03/04

1, 3, 5, 7 Exmoor Drive 12/01/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Exmoor Drive, 1, 3, 5, 7 1 Exmoor Drive Bromsgrove Worcs B61 0TW Lead Inspector Dianne Thompson Key Unannounced Inspection 25 and 30th April 2007 10:00 th Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.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 Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) 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 www.csci.org.uk Internet address Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.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 establishment are those for Care Homes for Adults 18-65. 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. Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Exmoor Drive, 1, 3, 5, 7 Address 1 Exmoor Drive Bromsgrove Worcs B61 0TW 01527 576591 01527 871853 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.worcestershire.gov.uk Worcestershire County Council Mrs Deanna Jayne Edwins Care Home 12 Category(ies) of Learning disability (12) registration, with number of places Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. A maximum of 4 persons may be accommodated in each unit. The home may accommodate people with a learning disability over 65 years of age. The home is primarily for adults with learning disability aged 18-65 but may accommodate service users beyond the age of 65 if their needs can still be met. The home may accommodate service users who have additional physical disability, mental disorder, and sensory impairment or dementia illness. 11.05.06 Date of last inspection Brief Description of the Service: Exmoor Drive is operated by Worcestershire County Council Social Care Services. It is a care home for 12 adults with learning disabilities, which may include people who have additional physical disabilities, dementia or mental health problems. The responsible individual is Mrs Amanda Nally and the service manager is Mrs Dee Edwins. The acting home’s manager is Karen Austin, who is to apply to be registered with the Commission for Social Care Inspection (CSCI). The home is purpose built on one level and opened in 1992. It is located in a residential area approximately one mile from the centre of Bromsgrove, on a bus route and there is a range of community facilities within close proximity to the home. The accommodation consists of three, self-contained units. Each unit has four bedrooms, a bathroom, a separate toilet, and an open plan lounge with dining and kitchenette areas. All of the service users’ bedrooms have a wash hand basin but no en-suites. Two of the units provide long-term care and one of the units continues to provide respite care, although it is planned to use the unit for long-term care in the future. The aim of the service is to provide appropriate support, advice and guidance in order to enable people who use the service to develop their individual potential and to participate as fully as possible within the community. The current fee for the service is £63.95 per week. Charges which are additional to the fee include: Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 5 • • • • Personal toiletries, clothing and electrical items Holidays Major extra outings Hairdressing Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The main purpose of this inspection was to see what the service at Exmoor Drive was like for the people who lived there. Records for people who use the service were examined, and a tour of the building was also carried out. Accumulated information including notifications to the Commission for Social Care Inspection (CSCI) was used to inform this report. Time was spent with people who use the service and staff on duty. Surveys were sent out to relatives and people who work in the medical services prior to the inspection visit. What the service does well: Information is available about the services offered at the home to help people choose whether or not to live at Exmoor Drive and if the home will meet their needs. People who use the service are helped and supported to lead active and interesting lives at Exmoor Drive. They are also supported to stay in touch with their families and to develop friendships. The home offers a balanced diet and promotes healthy eating for the welfare of everyone who uses the service. Personal and healthcare needs are written in care plans and provide information to make sure that care is provided in a way that people like. The home has a medication policy and procedure to make sure that all medication is given and stored safely. The home’s complaints procedure gives information about how to complain. Staff support people who use the service to have their say and to share any concerns they may have. Exmoor Drive is a safe and comfortable home. tidy. The home is kept clean and The home makes sure that suitable staff are employed and that all necessary checks are made to make sure that people who use the service are kept safe. Staff are trained to help them support people who use the service. The staff team understand their responsibilities and are committed to their role. They are supported and work together to provide everyone with consistent and good quality care. Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 7 The home is managed in an open and positive way. Worcestershire County Council (WCC) monitors the home in various ways to make sure the service continues to develop as people want and that the home remains a safe place to live and work in. What has improved since the last inspection? What they could do better: 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. Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People are given information about the services offered at the home to help them make an informed choice about whether they would like to live at Exmoor Drive and whether the home will meet their needs. The home should develop its own assessment form to make sure appropriate information is obtained. EVIDENCE: The home’s statement of purpose guide has been amended to provide up to date information about the home to help people decide if they wish to live at Exmoor Drive. A copy was sent to CSCI by the required date and meets the requirement of the previous inspection. A service user guide was seen on file. The guide has been revised, a copy has been given to each person who uses the service and a copy is available in each bungalow. The service user guide is being produced in an alternative format using pictures and symbols appropriate to the understanding for the people who use the service. The format should include details of activities, the contract and the complaints procedure and a copy given to each person who uses the service and their family. Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 10 The file for one person who had recently moved into the home was examined. A Community Care Assessment (CCA) was in place. However, the home still needs to develop its own assessment form, and not rely on CCA’s completed by social workers. The format of the assessment should allow for gathering additional detailed information to make sure the home is fully able to meet the needs of the person who is being assessed. The assessment process should be very detailed and care records should show that the home receives full information about people, their background, their needs, their likes and dislikes when they are referred for a placement. Information should be gathered from a range of sources such as other relevant professionals, visits to previous homes or schools, and discussions with family members. Following the inspection visit the manager forwarded a copy of the homes assessment form to the CSCI. A service agreement was in place for each of the files examined. The home should make this available in alternative formats, to include pictures and symbols that will make the information more accessible to people who use the service. Surveys were sent to people who use the service and their relatives prior to the inspection visit. One person indicated that they ‘had to move into the home very quickly and didn’t understand very much’, whereas another person indicated that they ‘had moved from another home and had visited many times and had lots of support’ when they moved in. Surveys from relatives confirmed that information about the home had been supplied and that people using the service had visited prior to moving into the home, although one response indicated they had ‘not received much information about the home or the way they work’. Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care plans provide staff with detailed information about individual’s assessed needs. They include risk assessments to show how risks are to be reduced and how to promote independence. People who use the service are supported to make choices and decisions in their daily lives and routines. EVIDENCE: Individual care plans have been developed since the previous inspection and now contain information to enable staff to provide care in a preferred and more consistent way. Plans focus on the needs of people and how these needs will be met. Care plans are now signed and dated, and updated when identified needs change or when the care plan is reviewed. This meets the requirement of the previous inspection. Files for two people who have different needs were examined. Case tracking provides a view of how the home responds to the diversity of needs and how this is being managed and supported. This is particularly evident where health Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 12 needs and disability requires greater input and support from all staff within the home. Relevant information and monitoring is provided in individual files to make sure all staff have the necessary information to provide quality care. People who use the service are allocated a key worker to oversee their care. Each key worker builds a closer relationship so they gain more understanding and knowledge of individual needs, goals and wishes. A monthly co-ordinators report is completed and included with the care plan to provide up to date information and regular monitoring. People who use the service have signed their care plans and have given consent for staff to use their care plans. Risk assessments are now completed for each person and are included in the care plans. This meets the requirement of the previous inspection. Surveys responses from relatives and carers indicated that they are kept informed about important matters and consulted about the decisions affecting the care of their relative. Two of the responses however indicated that they are not consulted about important matters. Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People receive help and encouragement to lead active and interesting lives and are supported to access facilities within the community. People are also supported to maintain links with their families and to develop friendships. The home offers a balanced menu and promotes healthy eating for the welfare of people who use the service. EVIDENCE: Only three people who use the service were at home at the time of the first inspection visit. Three people were at Padstone day services, one person was in Bromsgrove, two people were out with a member of staff, and one person was in hospital. It is evident from talking with people who use the service and with members of staff that the home provides a range of activities, both in-house and within the Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 14 local community. Activities within the home include aromatherapy, assisting with daily tasks, cooking, gardening, games, reading, watching TV and video, and listening to music. All activities should be recorded to reflect the lifestyle of people living at Exmoor drive, and include internal as well as external activities. The home has converted a communal lounge area into an activities room that includes a pool table, games and seating area. This room was being used at the time of the visit. External activities include attending Padstone day centre, the Odell centre, hairdressers, local pub, trips into town, theatre, cinema, bowling, holidays, shopping for food and clothes, buying books, and swimming. People who use the service have weekly meetings to discuss their plans, which includes such things as holidays and menus. Minutes are kept and are available on a file. People who use the service were asked about the home and they agreed that they like living at Exmoor Drive. Records show that people are supported to keep regular contact with their friends and family. All surveys indicated that relatives are satisfied with the overall care given by the home. The home provides balanced and varied meals, and records are now kept on the food charts. Food charts are held on individual files, but the information was not consistently recorded. There were gaps in the record sheets for the files examined. People were observed making drinks, and they confirmed they are able to get drinks and snacks when they want. Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Personal and healthcare needs are clearly identified in care plans. The plans provide information to promote consistency of care and support in a way that people prefer. The home has a medication policy and procedure that is followed to make sure that all medication is administered and stored safely for the protection of everyone who uses the service and staff. EVIDENCE: Care records and plans provide information about people’s physical and mental health and the support needed from staff to maintain their good hygiene and health. The care plans sampled contain information about how people prefer their personal care routines. Care plans are regularly reviewed and updated as required or sooner if identified needs change. All people who use the service have health action plans, and are supported by their key workers in maintaining their health care. Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 16 All people who use the service have signed consent to medication and treatment forms. Staff are able to communicate with people who use this service verbally and, in certain cases, with the additional use of gestures, sign language, and using objects of reference. Time was spent with people who were at home during the inspection visit. Everyone seemed to be comfortable and well cared for in the home. One person said that they liked living in the home and that the ‘staff are good’. People who use the service are well supported by medical services, which include GP’s, Learning Disability Team, Speech and Language therapists, chiropodist, psychiatric consultant, podiatrist, and optician. Arrangements are in place for preventative health services, such as dental checks and annual health screening. Staff on duty confirmed that all personal care is given in private to promote dignity for people who use the service. Medication administration and storage was checked. The home uses a monitored dosage system of medication administration. All procedures have been followed. Medication administration records were seen and appropriate recording is evident. Specimen staff signatures are recorded in the medication administration file. Information is available for all prescribed medication that gives details of possible side effects, the reason for the medication and the route of the medication. Risk assessments are in place for self-administration of medication. A risk assessment has been completed for using of a walking frame. This meets a requirement of the previous inspection. A risk assessment has been completed for a person who is at risk of choking. This risk assessment should be reviewed to indicate the action to be taken should choking occur. A discussion with staff indicated that incidents of choking do occur but through a combination of staff knowledge and experience that these incidents are managed. There was however, no evidence to show how these incidents of choking are monitored. Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are protected by information about how to complain, with appropriate information for staff provided. Staff support people to express their views and any concerns they may have. EVIDENCE: Exmoor Drive has a suitable complaints policy and procedure in place. The complaints procedure is made available to the people who use the service. A copy of the complaint form was seen on each bungalow’s notice board. People who use the service said they know what to do if they are unhappy or want to complain. The home has received three complaints during the past twelve months. All three complaints were investigated according to the home’s policy and procedures. All three complaints were upheld and action has been taken to respond to the issues. Of the six surveys returned five indicated that they are unaware of the home’s complaints procedure. All six respondents confirmed that they had not made any complaints to the home. The home is advised to send out copies of their complaints policy and procedure to all relatives. Staff complete training in relation to abuse. Vulnerable Adults training for all staff is scheduled for July 07. Discussion also takes place in supervision and staff meetings. Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 18 During the inspection visits staff were observed engaging with people who use the service in a supportive and respectful way. The home has relevant financial policies and procedures in place to make sure that money is kept safe for each person. People who use the service are supported to manage their own affairs, to keep their money in a safe place in their bedrooms or in the office. Appropriate risk assessments have been completed. People hold savings accounts and where necessary support is given to help them manage these. Safety to the home has been improved with the fitting of a security keypad to the front door. Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Exmoor Drive is a safe and comfortable home. The home is kept clean and tidy and makes sure that good hygiene and infection control is maintained. EVIDENCE: A tour of the home was completed. The home is clean and tidy with no unpleasant odours. People who use the service who were at home during the inspection visits were happy to show their bedrooms. All rooms are very individual and have been personalised. One person has their own computer in their room and uses this regularly. The building has been improved since the previous inspection with the installation of two new walk-in shower rooms. New shower units have been installed to existing facilities. A new Arjo bath has been installed and all bathrooms and corridors have been redecorated Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 20 The day lounge has become an activity room with a pool table, games, music players and comfy seating. Emergency call systems have been installed throughout the bungalows. These changes and improvements to the home meet the requirements of the previous inspection. Further improvements to the building are planned and include changing the large office into a quiet room (Snoezelen) facility, and moving the large office into the current communal kitchen. Upgrading of the kitchenettes in each bungalow has been agreed, and this will include the installation of dishwashers as advised during the previous inspection. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. All cleaning materials are stored in locked cupboards in the laundry room. Staff were observed wearing appropriate protective wear for the task being completed. Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staffing levels are being maintained and staff receive relevant training to help them meet the needs of people who use the service. The staff team understand their responsibilities and are well supported. They are working together to provide people who use the service with consistent and good quality care. The home’s recruitment policy and practices make sure that suitable staff are employed. All necessary checks are made to ensure the safety of everyone living at Exmoor Drive. EVIDENCE: Exmoor Drive has a stable staff team although recent sickness absence has been difficult at times to cover. Rotas demonstrate the home’s effort to make sure senior cover is available on each shift at all times, although this has been difficult to sustain more recently due to sickness absence. The home uses two local agencies when additional cover is needed as the numbers of relief staff has declined recently. The home is also looking to fill a 20-hour vacancy. At Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 22 the time of the inspection two regular relief members of staff were on annual leave. WCC provide regular staff training. Staff complete mandatory training such as health and safety, fire safety, first aid, food hygiene, moving and handling, and vulnerable adults. At the time of the inspection 53 of care staff have NVQ level 2 or above, and 9 staff hold a current first aid certificate. A training needs assessment has been carried out for the whole staff team and a copy supplied to CSCI. A record is kept of all training that is completed by all staff including relief and agency staff. This meets the requirement of the previous inspection. Training courses planned for the coming year include Dementia Awareness level 2, Dementia, autism, food hygiene, total communication, equality and diversity, epilepsy awareness, Health and Safety, medication and manual handling. However, it is disappointing to see that staff training on infection control has not been arranged following the recommendation of the previous inspection. WCC has a recruitment protocol that is followed for each recruitment campaign. The manager is involved in the selection and interview process, and is looking to develop ways in which people who use the service will be involved in this process. All newly employed staff complete an Induction Course. The Induction process also includes new staff being supported by senior staff to familiarise themselves with the people who use the service, the home, and safety matters. Staff confirmed that everyone completes an appropriate application form and that required references are obtained including one from their most recent employer. Appropriate criminal records and other checks are undertaken before their appointment is confirmed. Records for two members of staff were examined and demonstrate that full employment procedures are followed. Staff meetings are held regularly and minutes are available. Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is managed in an open and positive way. WCC monitors the home in various ways to ensure that the service continues to develop as people who use the service want, and that the home remains a safe place to live and work in. EVIDENCE: In the absence of the registered manager, Karen Austin Hatch is acting manager of the home for a period of twelve months. Karen is a qualified nurse of 10 years, and has many years experience working in a mental health unit and homes within Worcestershire. She has completed training relevant to the post, including mental health awareness, person centred planning, fire training for managers, and medication. Two deputy managers and two senior support Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 24 workers support Karen. Management responsibilities include organising dayto-day activities, health and safety promotion, staff supervision and induction. The home is moving towards the provision of a residential service although they are continuing to provide a respite service for one person where there is a commitment to do so. The home will also develop a service that provides care for care for people with dementia. A change to the home’s category of registration has been approved by CSCI. In respect of management support from the provider, WCC has Training and Human Resource Officers who are available to advise and support the home. Service manager meetings are held regularly. The provider’s monthly visits are one of the ways that WCC monitors the service and how the home is being run. Interviews with staff and people who use the service take place during these visits. An audit of the service, including records, environment, complaints received, finance and safety is completed. Any actions that may be needed to address shortfalls are specified. The resulting reports are also part of the home’s quality assurance and monitoring system and are intended to form an annual development plan for the service. A quality audit is scheduled to be completed May 07. The report of this audit will include the views of people who use the service, stakeholders and interested parties. Copies of this report should be made available to all. Regular monthly visit reports by the provider or their representatives are sent to CSCI. This meets the requirement of the previous inspection. Records show that monthly checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. Staff undertake all mandatory health and safety training topics. Generic risk assessments are in place. This meets the requirement of the previous inspection. The remedial work that was listed in the fire risk assessment has been completed. The home is working to make sure that all staff receive quarterly fire awareness training. This training took place in January 07 and is scheduled for May 07. This meets the requirement of the previous inspection. Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (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 CHOICE OF HOME Standard No Score 1 2 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 2 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA17 Regulation 16 Requirement The record of all food provided for people who use the service must be developed and maintained in sufficient detail to demonstrate whether the diet is nutritious, healthy and satisfactory. Timescale of 30/06/06 partially met. A record of all activities must be kept to demonstrate that people who use the service have access to and choose from a range of appropriate leisure activities. Timescale for action 30/08/07 2. YA14 16 30/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA1 YA22 Good Practice Recommendations The service agreement should be made available in way that people who use the service can understand it. The home is advised to send copies of their complaints policy and procedure to all relatives. Exmoor Drive, 1, 3, 5, 7 DS0000037488.V334548.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. 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