Inspection on 09/11/07 for 1 Old Road

This inspection was carried out on 9th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 Old Road 20/06/07

1 Old Road 10/08/06

1 Old Road 24/11/05

1 Old Road 11/07/05

1 Old Road 11/11/04

1 Old Road 18/02/04

1 Old Road 02/12/03

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Scic - Old Road, 1 1 Old Road Southam Warwickshire CV47 0HD Lead Inspector Jo Johnson Unannounced Inspection 9th November 2007 08:00 Scic - Old Road, 1 DS0000004307.V350564.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 Scic - Old Road, 1 DS0000004307.V350564.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. Scic - Old Road, 1 DS0000004307.V350564.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Scic - Old Road, 1 Address 1 Old Road Southam Warwickshire CV47 0HD 01789 298709 01789 296724 pam@stratfordmencap.org.uk 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) Stratford & District Mencap Ms Rachael Sass Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Scic - Old Road, 1 DS0000004307.V350564.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Ms Sass achieves the registered Managers Award by 1st September 2006. The home may accommodate one named service user within existing categories over the age of 65 years. 20th June 2007 Date of last inspection Brief Description of the Service: 1 Old Road is a semi-detached house, which provides accommodation for four adults who have learning disabilities. The ground floor has the communal accommodation, with a lounge that leads into a large open plan dining area and kitchen. There is a small utility room off the kitchen. The ground floor also has one bedroom with its en-suite WC and shower. There are three bedrooms on the first floor in addition to a bathroom and staff sleep in room/office. The organisation also operates a domiciliary care agency supporting approximately ten people in the Southam area from the sleep in room/ office. The manager is the registered manager for both the domiciliary care agency and the care home. The house has a rear garden and parking for cars at the front. Shops and village amenities are available locally. The property is owned by a Warwickshire housing association and held on lease by the care provider. Fees as detailed in people’s contracts for 2007/8 are £598.17 per week. Scic - Old Road, 1 DS0000004307.V350564.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. The manager supplied the commission with an AQAA (Annual Quality Assurance Assessment). Information from this has been used to make judgements about the service, and have been included in this report. Surveys were sent to all of the people living at the home and all were returned. All were positive about living at the home. Surveys were also sent to all of the staff working at the home. Information from surveys has been included in the report The inspection visit was unannounced (we did not let the home know that we were coming) and took place on 9th November at 8am. The inspection involved: • • • Observations of and talking/Makaton signing with the people who live at the home and the staff, deputy manager and manager. Observation of working practices and of the interaction between individuals and staff. Three people were identified for close examination by reading their, care plan, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’, where evidence is matched to outcomes for people. A tour of the environment was undertaken, and home records were sampled, including staff training and recruitment, health and safety, and staff rotas. • The inspector would like to thank the people who live at the home, deputy manager, manager and staff for their hospitality and cooperation during the inspection visits. What the service does well: Scic - Old Road, 1 DS0000004307.V350564.R01.S.doc Version 5.2 Page 6 The environment is warm and welcoming and the home is clean and tidy. The people living at the home have good relationships with staff. People living get on well with each other. People are supported to go out places and to go on holidays each year. Most people go to day or community services for part of the week and receive support to stay at home or do other things on some days. Staff are recruited safely. Staff have regular support and guidance meetings with their manager. There is a good training programme and the staff have been trained in the specialist needs of individuals living at the home. What has improved since the last inspection? What they could do better: Scic - Old Road, 1 DS0000004307.V350564.R01.S.doc Version 5.2 Page 7 People’s personal profiles and histories need to be updated in their care plans. This is so staff have full information about people, so they can meet all of their assessed needs and have a greater understanding of them as an individual. Staff need to have training on personal relationships and sexuality so that they can safely support and inform people who live at the home. ‘As required’ medication plans need to be written for homely remedies. This is so staff know when, how often and how much medication can be given safely. Staff must make sure that they complete peoples’ financial records at the time of any transaction. This is so mistakes are not made and that peoples’ finances are safely managed. The organisation must find alternative premises to operate the domiciliary care agency. This is so that the people have the full attention of the manager and staff working in the home. 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. Scic - Old Road, 1 DS0000004307.V350564.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 Scic - Old Road, 1 DS0000004307.V350564.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): 2, 5 Quality in this outcome area is good People’s needs are assessed and they are provided with information so that they are clear about their rights and entitlements at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection, one person has moved out of the home. Health and social care professionals and advocacy services were involved in the person’s move. The person, who had moved in shortly before the last inspection, was spoken with about how they had settled in. They said “ things are better since xxx has gone…I’m getting to know people a bit who live round here…I don’t want to visit my old house, I’ve got a new girlfriend who lives near here”. From discussion with the manager and the support that was given to the person who moved out, she is now confident and clear about when the home is not meeting people’s needs and what action to take make sure that they get the right support to move on if necessary. She also went through how she would ensure that any new person moving into the home would be properly assessed. Scic - Old Road, 1 DS0000004307.V350564.R01.S.doc Version 5.2 Page 10 Pictorial contracts have been reviewed and now include how people will be informed that the home can no longer meet their needs and what the process is for leaving. These were seen in all three people’s records. Scic - Old Road, 1 DS0000004307.V350564.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 There is a care planning system in place that gives staff the information they need to meet a majority of individuals’ needs. Risk management strategies are in place to meet the assessed and changing needs of the people living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three people’s assessments and care records were seen. Since the last inspection, all of the assessments and care plans have been reviewed. The information was up to date and was clear and easy to follow, there was not any conflicting or out of date information about people’s health conditions. Each section of assessment and care plan had a corresponding risk assessment. Risk assessments have been completed for all aspects of people’s day-to-day lives, activities and areas relating to their health and behaviours. Scic - Old Road, 1 DS0000004307.V350564.R01.S.doc Version 5.2 Page 12 The care plans now detail the actions staff need to take to support people with their daily living and personal care. One person went through their plan with the inspector. They showed where they had signed each section of the care plan. This shows that they have been involved in developing their plan. The practice of locking the downstairs doors stopped immediately after the last inspection. Two people spoken with said that they can now come downstairs at night whenever they want to. Each person’s file contained a personal profile. These were not up to date and did not give a full picture if people’s lives and who they had previously lived with and detail important milestones in their lives since and before moving into the home. It is important that these profiles are updated as one of the people living at the home has been diagnosed with dementia, another does not communicate verbally and the other has only recently moved into the home. This is so staff have full information about people, so they can meet all of their assessed needs and have a greater understanding of them as an individual. Discussions with people and their surveys show that they make decisions about what they do each day. Work has started on people’s ‘life story’ books. These books have photographs and items in them that show what the person has been doing in their lives. One person showed the inspector their book and they had written captions underneath. They said “it’s about me, we take the camera with us…I like churches and Michael Jackson and Elvis”. The life story work that has been completed so far is a good start and does show how people have been spending their time in a much more accessible format. However, there are not any dates recorded within the books and people may forget when it was that they did something. The life story work should include the month and year to help people remember. As already identified peoples’ written profiles must be updated and they need to be supported by ‘Life history’ work. ‘Life history’ books should be developed that include details and photographs of their ‘history’ such as family, friends, where they have lived, pets, work etc. These life history books will assist both the person and staff in remembering their past and will assist staff to have a greater understanding of them as an individual. Scic - Old Road, 1 DS0000004307.V350564.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 People participate in a range of social, leisure, and educational and occupational opportunities. People have opportunities to maintain appropriate and fulfilling lifestyles in and outside the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the start of the inspection, all three people were at home. Two of the people were getting ready to go their day services. The remaining person got up later and spent time with the inspector then went to the library and out for lunch with staff member. From discussion, Makaton signing with people and their surveys show that they can choose how to spend their time during the week and that can do what they want at the weekend. Each person has some planned days at day services or community activities. One person said “ I tried ‘Gateway’ but Scic - Old Road, 1 DS0000004307.V350564.R01.S.doc Version 5.2 Page 14 didn’t like it, I go to No 7 for a coffee and to the library…I’m going to try art at the college”. Another person Makaton signed and pointed to pictures in their communication book ‘ car’, ‘bowling’, ‘holiday’, ‘music’ and ‘happy’. Since the last inspection, people have been supported to maintain important personal relationships. One person who lived at the home for many years has moved out and staff have been taking people to see them on a weekly basis. One person said, “ we go and see XXX in his new house, staff takes us”. Another person who had previous close personal relationship with someone they used to live with, said that they had been keeping in touch by telephone but had chosen to not to visit because they now have a new partner. People said that they can have friends and family to visit and they can go and visit friends who live in the locality. One person said, “ I like churches and I am religious” another person has a job in the church on a Friday. The menus show that people are provided with a well-balanced and nutritious diet. All food being stored in the kitchen looked fresh and was well within the use by date. People go food shopping with staff support if they want to. They said or signed that they enjoyed the food provided by the home. One person said, “I do cooking, I made soup following the cooking book, it was good”. Another person who does not communicate verbally chooses the food they want by using a photographic menu book. Scic - Old Road, 1 DS0000004307.V350564.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 adequate. The health and personal care that people in this home receive is based on their individual needs. Medication systems in place are largely safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were positive relationships and interactions observed between staff and the people who live at the home. People commented that they know and get on well with the staff and that they treat them well. One person said, “new staff are ok all my friends”, another person said, “I get on with staff at the moment”, the other person pointed to a ‘happy’ face in their communication book when asked about staff. One person had put on their survey and during discussions that staff do not use their full name. They said, “ I call myself XXX (full name), my mum and dad called me that name, I don’t like XXX (shortened name)”. Staff must Scic - Old Road, 1 DS0000004307.V350564.R01.S.doc Version 5.2 Page 16 always use people’s preferred name and this should be recorded on their care plan. There is a gender mix of staff so that peoples’ gender preferences can be met. One person has a new personal relationship and from discussion with the manager. The staff and manager are not confident that they have the skills and knowledge to safely support and inform the individuals involved. Staff must be provided with personal relationship and sexuality training to make sure that they can safely inform and support this individual. Staff surveys show that they ‘usually’ or ‘sometimes’ have enough information, support and experience to meet peoples’ diverse needs. Staff should be provided with equality and diversity training so that they are able to meet people’s diverse needs. People’s surveys show that someone always helps them when they are not well. One person was going to the doctors the morning of the inspection. Since the last inspection, people’s health records and care plans showed that their right to good-quality physical and mental health care is being promoted. The records show that as part of promoting their health people make regular visits to a dentist, optician, specific health consultants, physiotherapists, speech and language therapists, learning disability nurses, their GP and a chiropodist when needed. The medication systems at the home are greatly improved. The local pharmacy is now printing out medication administration records and those seen were correctly completely and tallied with the medications kept at the home. The manager has written to the local GP to seek advice for the PRN (as needed) plans in place. The importance of safe medication administration has been raised at staff meeting and has been raised with individual staff when necessary. There are now medication plans and risk assessments in place for each person. Paracetamol and ibrufen have recently been used in the short term to manage joint pain on the advice of the local GP. There must be a PRN (as needed) medication plan in place when these homely medicines are routinely used for pain management. These plans need to include under what circumstances it is to be given, how long between doses, what is the maximum dose in 24 hours and whether it can be taken with other medications. It is recommended that these plans be kept with the administration records so that staff can easily refer to them. Scic - Old Road, 1 DS0000004307.V350564.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 adequate Complaints and safeguarding procedures make sure that people’s views are listened to and they feel safe from harm. Shortfalls in the safe management of people’s finances may place them at risk of money mismanagement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People have access to a complaints policy, which is in symbol and large print format and includes information about the Commission for Social Care Inspection. However, this is out of date and the contact details include the previous Chair of Trustees of the organisation and the old telephone number of the commission. This should be updated. There have been no complaints made to us about the home since the last inspection. The record of complaints for the care home and the domiciliary care agency has now been separated. People said they felt safe and would know who to talk to if they were unhappy. They said, “talk to everyone and they’ll sort it out” and “if not happy talk to staff”. All of the surveys showed that people know who to speak to if they are unhappy and know how to make a complaint. Scic - Old Road, 1 DS0000004307.V350564.R01.S.doc Version 5.2 Page 18 Staff spoken with and surveys show that they know how to support people to complain. The staff said all of the people had a pictorial guide on how to keep safe and what things they need to report to staff. Staff spoken with confirmed that they had been provided with prevention of abuse training at various times. They said that Whistle blowing and Protection of Vulnerable Adult information is included in their induction training. Staff should have periodic refresher training on adult protection and whistle blowing so that they remain confident in how to recognise and report any allegations of abuse. There have been no adult protection referrals since the last inspection. All the people’s personal monies kept at the home were checked. The records did not balance with the individual monies kept in the safe, as that morning money given to an individual but had not been recorded on their sheet and another person had monies recorded on their balance sheet but not taken out of their tin. Staff need to make sure that they complete individual’s balance sheets at the time of giving someone their money so that mistakes are not made. Scic - Old Road, 1 DS0000004307.V350564.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 The home is maintained and furnished so that people live in a clean, comfortable and homely environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a warm and welcoming atmosphere in the home and at the time of the visit, it was homely and comfortable. The manager gave a tour of the communal areas of the house and went through the planned and ongoing redecoration and replacement programme. The home was clean and free from any offensive odours. Following the last inspection there is improved signage around the kitchen so that people know what is stored in each cupboard. Scic - Old Road, 1 DS0000004307.V350564.R01.S.doc Version 5.2 Page 20 One person has been provided with new bedroom furniture since the last inspection. They said “have new drawers in my bedroom and new floor” Scic - Old Road, 1 DS0000004307.V350564.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, 35,36 Quality in this outcome area is good The people living in this home are protected by robust recruitment practices and supported by a skilled and competent staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation of care practice and discussion with the manager and staff members on duty at the time showed that positive relationships exist between the people and the staff supporting them. There is now a photographic staff rota on display in the kitchen so that people know who is on duty when. One person who had previously struggled top remember staff names because of their dementia said, “ I remember staff with photos, helps me when I come back”. Following the last inspection the manager now keeps the staffing levels under review and following one person moving out the impact on staffing levels has reduced. Scic - Old Road, 1 DS0000004307.V350564.R01.S.doc Version 5.2 Page 22 The manager has informed the commission under regulation 37 of any staff disciplinary actions that involve staff who work both in the care home and domiciliary care service. This was a requirement at the last inspection. The AQAA (Annual Quality Assurance Assessment) and the training chart in the home shows that staff have accessed training in the full range of mandatory, health and safety related training, (e.g. first aid, food hygiene and fire safety) as well as specialist care courses, such as dementia and epilepsy. The two most recently recruited staff records were seen. They included all of the necessary documentation to demonstrate that the staff are suitable to work with people at the home. There were CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) checks and references for all of the staff. As previously identified in the report there are some areas that staff need further skills and knowledge such as, equality and diversity and sexuality and personal relationships. Discussion with staff, the manager and records show that they had regular supervision and staff meetings. Staff spoken with said they had regular supervision and staff meetings. Scic - Old Road, 1 DS0000004307.V350564.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 People benefit from living in an improving home. They are able to express their views of the service provision and know that their views will be listened to and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been in post for two years and advised the inspector that she has now completed the Registered Manager’s Award. Following the last inspection, the manager received additional support from the organisation’s assistant service manager, who gave guidance as to how to improve the outcomes and quality of care to the people living the home. There Scic - Old Road, 1 DS0000004307.V350564.R01.S.doc Version 5.2 Page 24 has been good progress since the last inspection, majority of the requirements have been met and the outcomes for people living at the home have improved. The organisation has now identified that the domiciliary care agency that operates from the care home will move to the organisation’s head office. However following the flooding of the head office this will not happen until February 2008 when the organisation is able to move back into it’s offices. The inspector has discussed this with the chief executive and has agreed to amend the timescale for the move. They are currently operating from temporary offices. From discussion with the manager and deputy manager the operation of the domiciliary care agency still has an impact on the people living at the home as all telephone calls come in on their house telephone line. A separate means of domiciliary care related calls to the manager must be sought to free up the house phone for people who live there. The manager has started to record when there are house meetings and any decisions that have been made. These informal meetings should continue. The people living at the home are surveyed for their views on an annual basis. The manager gives the surveys to the day service so that someone independent supports them to complete the surveys. The outcomes of this consultation are summarised and fed into the development plan for the home. The organisation’s quality assurance system has been recently been reviewed and will now include formal consultation with families and professionals involved with people. A representative of the organisation carries out monthly monitoring visits and copies of the reports are kept at the home. The reports show that suitable arrangements are in place for monitoring the work of the home and provide an opportunity for the visitor to seek the views of people using the service and to check significant records, such as accidents, incidents and complaints. Information provided by the manager in the AQAA shows that relevant Health and Safety checks and maintenance are being carried out at the home. A number of Health and Safety records were checked, including the fire safety log. These records showed that health and safety matters are well managed. Scic - Old Road, 1 DS0000004307.V350564.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 x 2 3 3 x 4 x 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 2 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 3 13 4 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x 3 x 3 x x 3 x Scic - Old Road, 1 DS0000004307.V350564.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? 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 YA6 Regulation 14(2)(b) 15(2)(b) Requirement People’s care plan profiles must be updated. This is so staff have full information about people, so they can meet all of their assessed needs and have a greater understanding of them as an individual. Staff must be provided with personal relationship and sexuality training. This is to make sure that they can safely inform and support people. 3 YA20 13(2) There must be a PRN (as needed) medication plan in place when these homely medicines are routinely used for pain management. These plans need to include under what circumstances it is to be given, how long between doses, what is the maximum dose in 24 hours and whether it can be taken with other medications. This is so that staff know how Scic - Old Road, 1 DS0000004307.V350564.R01.S.doc Version 5.2 Page 27 Timescale for action 01/03/08 2 YA18 18(1)(c) 01/06/08 01/02/08 and when to safely administer as and when medication. 4 YA23 12(1) 13(6) Staff must make sure that they complete peoples’ financial records at the time of any transaction. This is so mistakes are not made and that peoples’ finances are safely managed. The organisation must find alternative premises to operate the domiciliary care agency. Previous timescale 01/12/07 was amended with the agreement of the inspector. 01/01/08 4 YA37 Care Standards Act 2000 01/03/08 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 Refer to Standard YA6 Good Practice Recommendations Staff should continue to develop ‘life story’ books/works with people living at the home, as these give a much more interesting picture of how people have been spending their time and people may find them easier to follow than written records. These should include the month and year so that people can remember when they did things. 2 YA6 As people living at the home have changing needs, it is important that ‘life history’ books are also developed that includes details and photographs of their ‘history’ such as family, friends, where they have lived, pets, work etc. These life history books will assist both the person and staff in remembering their past and will assist staff to have a greater understanding of them as an individual. Scic - Old Road, 1 DS0000004307.V350564.R01.S.doc Version 5.2 Page 28 3 YA18 Staff should always use people’s preferred name and this should be recorded on their care plan. Staff should be provided with equality and diversity training so that they are able to meet people’s diverse needs. It is recommended that PRN medication plans be kept with the administration records so that staff can easily refer to them. The contact details in the complaints procedures of the chair of trustees and the commission should be updated. This is so people know whom they can contact to make a complaint. Staff should have periodic refresher training on adult protection and whistle blowing so that they remain confident in how to recognise and report any allegations of abuse. 4 YA18 5 YA20 6 YA22 7 YA23 Scic - Old Road, 1 DS0000004307.V350564.R01.S.doc Version 5.2 Page 29 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. Extracts may not be used or reproduced without the express permission of CSCI Scic - Old Road, 1 DS0000004307.V350564.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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