Inspection on 05/03/08 for 1 Chantry Close

This inspection was carried out on 5th March 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

1 Chantry Close 14/02/07

1 Chantry Close 15/03/06

1 Chantry Close 09/08/05

1 Chantry Close 15/02/05

1 Chantry Close 08/09/04

Similar services:

Aston Court Nursing Home

Breme

Ravenhurst

Westmead

Ashcroft Hollow Nursing Home

Bricklehampton Hall Nursing Home

Briar Hill House

Radbrook Nursing Home

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

CARE HOME ADULTS 18-65 Chantry Close, 1 1 Chantry Close Tenbury Wells Worcestershire WR15 8QE Lead Inspector Jean Littler Unannounced Inspection 5 March 2008 1:00 th Chantry Close, 1 DS0000018483.V355426.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 Chantry Close, 1 DS0000018483.V355426.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. Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chantry Close, 1 Address 1 Chantry Close Tenbury Wells Worcestershire WR15 8QE 01905 611147 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.scope.org.uk SCOPE Mr Andrew Joseph Deakin Care Home 4 Category(ies) of Physical disability (4), Physical disability over 65 registration, with number years of age (1) of places Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is primarily for people under 65 years of age with a physical disability, may also accommodate people with an additional learning disability 14th February 2007 Date of last inspection Brief Description of the Service: Chantry Close was opened in 1994 and is part of a local community project set up by SCOPE called 1st key Worcestershire. SCOPE is a national organisation and a registered charity providing a range of services for people with cerebral palsy and other physical disabilities. The 1st key office is at Unit 3, Lowesmoor Wharf, Lowesmoor, Worcester WR1 2RS (telephone no 01905 611147) and the service’s registered manager (Mr Andrew Deakin) is based there. The home provides accommodation with personal care for four adults who require care due to physical disabilities and may also have a learning disability. The house is situated in a quiet cul-de-sac close to the centre of Tenbury Wells, which is a busy market town. It has a very pleasant outlook towards the parish church and the river beyond. The property is owned by a housing association who have responsibility for it’s ongoing maintenance. Information about the home is provided in a statement of purpose and service users’ guide, which are available from the home and 1st key office. The fees in 2007 ranged between £37.343 up to £52.000 per year. People have to pay for personal items and services such as hairdressing, newspapers & magazines, personal shopping, travel & telephone calls and chiropody. Funding for activities and holidays is agreed between 1st key and each service user’s funding authority. Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was carried out over 4 hours in the afternoon. Two support staff helped with the process. We spoke with staff and looked around the house. Two people showed us their bedrooms. Representatives of people who live in the Home filled out surveys to give us their views. We looked at some records such as care plans and medication. The manager sent information to us, the commission, before the visit. What the service does well: New people are supported to visit and try out the service before moving in. People’s needs and wishes are written in their care plans. People are supported to have their health and physical care needs met in the way they prefer. People can spend time doing things they like at home and in the community. People are supported to stay in touch with their families and friends. People have a comfortable, clean and safe home that meets their needs. Each person has their own single bedroom with their own things. Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 6 People have a choice about meals and enjoy their mealtimes. People’s medication is being safely managed. People like the staff who support them. All the staff are qualified. People feel their views are listened to. 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. Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 7 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 Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 8 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, 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are given information about the home to help them decide if they may want to live there. Their needs are assessed prior to a placement being offered. EVIDENCE: SCOPE provides written information documents about the service, including a statement of purpose and service users’ guide. There is also written guidance on assessing prospective service users’ needs when referrals are received. The manager reported in the Annual Quality Assurance Assessment (the AQAA is information managers have to return to us, the commission, before an inspection) that an individual needs assessment is completed prior to prospective service user joining the service. This information is taken from the individual, their local authority, family members and their current placement. In addition to looking at individual needs the care plan also explores and identifies activities and outcomes the individual wishes to follow. Individuals are offered a copy of their care plan and contract of care, including tenancy agreement at the home. Service users are allocated a contact person whom they can speak to and ask any questions about the home. He plans to further improve arrangements by recording when service users have received the service user guide and by developing the guide and brochure into accessible formats. Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 9 The manager reported that the Statement of Purpose and Guide have been updated since the last inspection. Staff were not able to provide us with a copy of these documents. Copies should be held in the Home. A new service user had moved in just before the last inspection and he reported then that he was given information about the home and asked about moving in. He visited with his keyworker and then stayed overnight so he could meet the other service users and staff. Staff at the home were able to look at his care plan before it was agreed that he would move in for a trial stay. A review meeting was held at the end of the trial period with the service user and other relevant people to formally agree the move becoming permanent. The existing service users were consulted as part of the process. The current group seem very compatible. Service users indicated in their surveys that they were offered a choice about moving in and they are pleased with the service they receive. Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 10 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 this visit to the service. Service users’ needs are recorded in their care plans. They are enabled to make decisions and choices in their daily lives and routines. They are encouraged to take reasonable risks to be independent and live interesting lives. EVIDENCE: One of the service user’s care records was sampled. The man was aware he had a plan and he gave his permission for us to see it. The plan included information about his background and history, preferred daily routines and support needs. The manager reported that service users are fully involved in drawing up and reviewing their own plans. However the plan had not been written in a way that would help the person understand the information. Staff were recording the main events of each day such as activities, family contact and health issues. These notes would provide useful information to monitor the wellbeing of the person. Risk assessments have been carried out covering relevant areas. People are being encouraged to take reasonable risks to promote their independence e.g. staying in the house alone and going out Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 11 alone. The senior said she keeps all the care plan information up to date and consults service users regularly. Review meetings are held every six months. The staff team is small and it is clear that staff and service users know each other very well. The senior said a keyworker system is not in place, however, the manager reported in the AQAA that there is. Keyworking is considered to be good practice and may help support the planned implementation of person centred planning and health action plans. Staff were observed to enable people to make decisions and choices in their daily lives and routines e.g. about who supports them, what time to get up etc. One person has some hearing loss and it is positive that he and a worker have learned some sign language. As this has proved successful other staff should learn and use the signing as well. One person has Autism Spectrum Disorder, however his care plan did not reflect a full understanding of the condition and his associated needs. In one part he is described as lazy when a lack of motivation may be linked to ASD. Information did not seem to be being presented to him in other formats to reinforce the verbal communication and aid his understanding. A communication assessment by a speech and language therapist with ASD knowledge should be considered. Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 12 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 excellent. This judgement has been made using available evidence including this visit to the service. Service users are enabled to go out and pursue activities they enjoy and are meaningful to them. They are encouraged to mix within the local community and staff also support them to maintain links with their family and friends. Their rights are being respected on the whole but some restrictions may be unnecessary. Staff ensure that service users receive meals they have chosen, whilst aiming to promote healthy eating. Mealtimes are part of the social life of the home. EVIDENCE: The manager reported that service users are encouraged to be as independent as possible to make their own informed decisions and choices. Positive relationships with advocates, friends and family are actively encouraged. People are supported to access the local community facillities and flexible and innovative responses are made when service users want to change activities. Everyone had plans for the day and had been out or went out during the Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 13 inspection. Some service users attend a college course or workshop and one person has a voluntary job in a service for older people. One of the workers is a community development worker and she works as a second worker three days a week to facilitate outings. Service users said in their surveys that they decide what they do. Some regular activities are attended and one off activities like the cinema are also arranged. Each person has a day once or twice a month when they plan what they want to do and spend the day with one of the staff e.g. going clothes shopping and having a meal out. Holidays are arranged and all went away in 2007. Residents’ meetings are held so ideas and views can be discussed. The minutes from the February meeting showed that holiday plans had been discussed. Passports are being arranged to enable people to go abroad. Service users are encouraged to take responsibility for as many aspects of their daily lives as they are able to e.g. what to eat, what activities to attend. They decide their own routines, although one man has restrictions on how often he has a cigarette for financial reasons but there is a risk assessment about this and he does understand the situation. One person has a telephone in her room. She and two others go out alone and everyone helps around the house, doing their own laundry etc. This person does not like the metal grill that is placed over her storage heater in her room. Staff reported that this was essential in case she fell and burnt herself. This decision should be reviewed in light of the Mental Capacity Act 2005 as she is clearly capable of making an informed decision about this risk. Decision making processes should be clearly documented to evidence that the Act is being implemented. Two service users keep their own personal allowance. The others money is held by the staff in the downstairs cupboard. Although both may need support to manage their money consideration should be given to them keeping their money in their bedrooms, in a more normal and person centred way. Their financial risk assessments should be reviewed to explore if any restrictions will be needed such as staff keeping the key or the money in the tin being limited. One man showed us his records that evidenced he was spending his money on appropriate things e.g. outings and toiletries. There is a numbering and logging system for receipts but the large number of loose receipts in his tin indicated the system needed to be improved. Staff said the receipts are sent to the head office periodically with the log sheets. She assumed these are checked by the manager and that he would raise any issues, but there is no evidence that monitoring occurs even though he visits the service regularly. There is an open and relaxed atmosphere in the home and representatives confirm in surveys that they are made welcome and are kept appropriately informed. Staff also support service users to keep in touch with and make regular visits to relatives who live away. Staff reported that food is purchased locally and the service users are enabled to choose what they want each day. They take turn choosing the meat for the Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 14 Sunday roasts. A worker said some people help cook on a Thursday. It was not clear why people are not enabled to help on a daily basis. The manager reported that guidance and support is offered about healthy optioms and people take their meals at times vary to suit depending on activities and wishes. Service users each choose their meals, although mostly have main meals together. Staff encourage people to have fresh fruit & vegetables and healthier food options, e.g. yoghurts, rice and pasta. Most meals are freshly cooked and they always have a roast on Sunday. None of the service users require a special diet and one service user keeps an individual record of meals taken. Service users say they like the food and that mealtimes are flexibly arranged, to suit them. Chantry Close, 1 DS0000018483.V355426.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 this visit to the service. Service users’ personal and health care needs are being met appropriately with staff support and their medicines are being managed safely. EVIDENCE: The manager reported AQAA that service users are supported in their chosen manner to maintain their personal hygiene and health needs, including being supported to take medication. Staff work at all times ensuring individuals needs and rights are observed, providing personal care and support with privacy and dignity. Care is delivered consistently by staff who have excellent knowledge of individuals needs. It is led by the service user and offered sensitively and flexibly in response to their changing needs. Service users confirmed in surveys and in discussions that they were satisfied with how they are supported by the staff. The care plan sampled contained information about how the person preferred to be supported e.g. with shaving. It also referred to areas where the person is independent and does not need support. Staff are provided with training about privacy and dignity and core safety issues such as moving and handling. There is always a senior to confer with in the organisation if staff need support about a health or care matter. Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 16 Accidents are recorded and health concerns logged and monitored. One person’s records showed he had had an annual well person check and been to the dentists. The manager reported that service users are encouraged to weigh themselves each month and can gain advice if needed about diet from the GP surgery. He and the team leader have had training on completing health action plans and these are going to be developed. A social worker reported that staff understand when to make a referral for professional health input. Regarding medication SCOPE provides general policies & procedures for the management of medicines in their care services and there are also specific procedures for the Home. Each service user has a written profile of their prescribed medicines, where any possible side effects are highlighted. Medication is stored in two places. Any stocks are held in a metal cabinet in the staff room and the medicines in use are held in a wooden cabinet downstairs. This is quite solid but as it is wooden it is not up to professional security standards. The records sampled showed that medicines were being administered to service users correctly. A stock check is carried out each month and the pharmacist signs to say they have received any returned medicines. One service user manages some of her own medications, although staff support her to obtain the medication and keep records of what is received. A risk assessment is in place regarding this. All staff have completed some training relating to medication. The manager did not report in the AQAA if the planned ‘safe handling of medicines’ course had been held for workers since the last inspection. Chantry Close, 1 DS0000018483.V355426.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 this visit to the service. Service users are enabled to raise concerns and express their views and they have confidence these will be dealt with appropriately. Arrangements are in place to help protect them from abuse. EVIDENCE: The manager reported that SCOPE has a formal complaints procedure and all staff have recently attended a training session on complaints. There is a whistle blowing policy in place and all staff were made aware of this at the complaints training. Scope has an in depth adult protection policy and all services have a designated adult protection advisor. All new staff are informed of the above policies as part of their induction package and a record is kept of all complaints. No complaints or protection concerns have been received since the last inspection. The manager reported that all service users now have an advocate who would support them to raise any concers. There are plans to improve arrangements by organising refresher training on adult protection, provide an improved DVD version of the complaints procedure for service users and offer service users training in the complaints process. No complaints or protection matters have been raised with the commission. There seemed to be an open atmosphere in the home and service users clearly feel able to freely express their views. Surveys showed they know who to talk to if they have concerns and they feel confident they will be supported to express their views. One had recently met the manager to tell him of her concerns about a current staffing matter. Representatives confirmed they knew how to raise any concerns and felt these would be listened to. Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 18 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, 25, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. Service users have a comfortable and well maintained home within the community that is suitably adapted and equipped to meet their special needs. EVIDENCE: Chantry Close is in a pleasant and convenient location, close to Tenbury Wells centre, whilst also having a view of a Church, the river and countryside. The town is within easy walking and wheelchair distance and has a good variety of shops, pubs and cafes, a leisure centre, cinema, library and other amenities. The property is owned by a social landlord (Nexus Housing Association), which leases it to SCOPE. Nexus retains responsibility for its ongoing maintenance and upgrading. The manager reported that service users have chosen how their rooms are decorated; all areas of the home are accessible; all equipment has been serviced and tested and checks are carried out on fire alarms, fridge and freezer temperatures etc. The landlord carries out checks on gas and water systems. He reported that since the last inspection the house has been Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 19 redecorated, the heating system replaced, the electrics updated and a new extractor fan fitted in the kitchen. He plans to improve arrangements by developing a rolling programme of refurbishment and a garden improvement plan. The home seemed clean and some service users got involved with domestic tasks. Staff are provided with protective clothing and systems are in place to help reduce cross infection. Environmental Health inspected during 2007 and have issued the Home with a 4 star rating. The accommodation is made up from two ordinary terrace houses joined together internally. The rooms are not particularly large. The table in the lounge/diner has to be pushed back against the wall when not in use and one service user watches television from her bed as she cannot fit an armchair in her room. The garden is very small and more like a yard, however the communal car park area at the front can be used e.g. one service user was seen riding her bike. Service users said in their surveys and during the visit that they are happy with their home and are well settled within the local community. They have single bedrooms with sinks but have to share bathroom facilities. The room seen was well personalised, reflecting the person’s interests. She said this is her private space and everyone respects that. She has chosen not to have a lock fitted but others have. One person is a wheelchair user and he has a ground floor bedroom. There is a stair lift and grab rails but as the other bedrooms are upstairs they are not suitable for people with more severe physical disabilities. Aids, adaptations and equipment have been provided as needed e.g. a light flashes in one person’s bedroom when the fire alarm rings as he has some hearing loss. They include a call bell system throughout, a frame around one toilet and other grab rails. Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 20 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, 33, 34, 35, 36. Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. Service users continue to be supported by a stable and effective staff team who know them well. Staff are suitably experienced and trained. People are protected by the recruitment procedures, which should help to ensure that only suitable staff are employed. EVIDENCE: The staff team comprises of five support workers, including a senior and a community development worker. They have all worked at the home for over three years. Two have been employed by SCOPE for over twenty years and have worked at Chantry Close since the Home was set up. A team leader supports this Home and two other services in Worcestershire. She is office based with the registered manager. The role of the seniors within the organisation is currently being reviewed and this has led to the senior considering giving in her notice. This has caused some anxiety for at least one of the service users after they were told at a recent residents meeting. Both staff and the service user spoken with felt the staffing levels are sufficient. The rota showed the care staff element but the hours provided by the community development worker were not shown. These should be included as they are an essential part of the service provided. Staff often Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 21 work alone but because service users are quite independent this does not seem to restrict activities. All service users seemed to relate well to the staff on duty and two said in their surveys that staff treated them well and listened to them. There are no staff vacancies and had been no new staff for some time. This is positive for consistency of care, but it was again not possible to discuss the recent appointment and recruitment of a new worker. The manager reported that rigorous recruitment checks are carried out and that service users are invited to be on the panel during recruitment. It has been previously confirmed in this and the other 1st key care homes that SCOPE operate thorough recruitment procedures. He did not report if the recommendation about a recruitment check list being held at the Home, (as the main records are held at the head office) had been implemented so this has been brought forward. Staff confirmed that they have all attended the standard courses provided by SCOPE and refresher courses are provided in some areas. All staff hold a current first aid certificate. The manager reported that staff are provided with a comprehensive induction programme which is concurrent with the common induction standards for care. This then leads to staff working towards their NVQ Level 2 after their probation period. Current staff have all completed a relevant NVQ Award and one is an NVQ assessor. Last year courses were provided on equality, person centred planning and complaints. The training plan for 2008 includes Adult Protection, the Mental Capacity Act and finance. Feedback in surveys was positive about the staffing e.g. one advocate said, ‘The staff have an excellent understanding of the clients needs. The staff should be recognised for their patience and care’. The manager reported that there is always someone on call to support staff and they are provided with bi monthly supervisions and an annual appraisal. He feels support would be improved if supervisions were monthly. Staff confirmed they felt supported in their role by the manager and team leader. Team meetings are held regularly, however the minutes seen did not say if the manager had attended. Communication is reported to be good as the small team works well together for the benefit of service users. Their commitment to providing a good service is apparent. Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 22 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, 41, 42. Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. The service users benefit from a well run service. Suitable arrangements are in place to keep people safe and their welfare is promoted. EVIDENCE: The registered manager, Mr Deakin, is the community service manager for 1st key Worcestershire and responsible for three services. The management arrangements are therefore unusual as he is based at the 1sy Key office and does not run the home day-to-day. He is responsible for 1st key’s business plan, finance, service performance and policies & procedures. A team leader (also office based) is responsible for monitoring the service delivery and quality. The senior based in the Home manages the home’s staff team, service users’ needs and some records. Mr Deakin is suitably experienced and both he and team leader have gained the NVQ Registered Managers Award since the last inspection. The senior holds an NVQ 3. The manager reported that an area he could improve is attending at least 50 of the staff meetings held in the Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 23 Home. He and the team leader are only responsible for three services so it would seem reasonable for one of them to attend every meeting to demonstrate they are actively managing the service. The manager completed the AQAA on time and provided reasonably detailed information about the service. Some areas were brief such as arrangements for activities and the management of medication. The recommendations from the last inspection were not mentioned. An AQAA may not always be supported by information gathered at an inspection so full information is essential to enable us to make an accurate assessment of the outcomes for service users. It is positive that areas where the service can be further improved were identified. A quality assurance system was being put in place at the time of the last inspection. The manager did not explain how effective this had been but said quality assurance is now being reviewed by the organisation. He did report that the views of stakeholders are gained at individual people’s review meetings, service user surveys and monthly house meetings. The findings from the quality assurance process should be more clearly reflected in the next AQAA. Health and safety management systems are in place such as monthly safety audits and regular checks of water and fridge temperatures etc. All staff undertake mandatory training. The manager reported that all equipment and fire prevention systems have been serviced regularly. A record of fire checks and drills was seen in the Home. The service users take part in the drills. Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 24 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 3 3 3 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 3 26 X 27 X 28 2 29 3 30 3 STAFFING Standard No Score 31 X 32 4 33 4 34 3 35 3 36 3 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 4 13 3 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 X 2 3 x Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NA 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. Standard Regulation Requirement Timescale for action 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 YA16 YA35 Good Practice Recommendations The Service User’s Guide should be developed into a more accessible format. Provide Mental Capacity Act 2005 training for all staff and ensure people are supported to make informed choices when they have the capacity to do this. Support people to keep their money in their bedrooms. Develop person centred care plans and health action plan. Arrange adult protection refresher training for all staff. Include all staffs’ hours on the rota. A checklist should be kept in the home when staff are appointed to confirm their conditions of employment and that satisfactory references and checks were received DS0000018483.V355426.R01.S.doc Version 5.2 Page 26 3 4 5 6 7 YA16 YA19 YA6 YA23 YA33 YA41 YA34 Chantry Close, 1 before they started work at the home. These details to have been checked and verified by a registered person. Brought forward. 8 YA35 YA6 Provide staff with training on Autism Spectrum Disorder and develop the care plan information and communication systems for the person with this condition. The manager or team leader should always attend staff meetings to better demonstrate that they are actively managing the service. A plan should be produced showing aims for the continual improvement of the home in the year ahead. This should reflect the views of service users and significant other people in the way that the service develops and include the improvement aims noted in the AQAA. Brought forward. Review the way service user’s expenditure receipts are managed. The manager should demonstrate that he monitors financial records when he visits the service. 9 YA37 10 YA39 11 YA41 Chantry Close, 1 DS0000018483.V355426.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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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