Inspection on 27/06/08 for 1 Sheepfold Avenue

This inspection was carried out on 27th June 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 Sheepfold Avenue 23/08/06

1 Sheepfold Avenue 13/12/05

1 Sheepfold Avenue 16/07/05

1 Sheepfold Avenue 07/02/05

1 Sheepfold Avenue 24/08/04

1 Sheepfold Avenue 28/01/03

Similar services:

Lyncol House

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 1 Sheepfold Avenue Rustington Littlehampton West Sussex BN16 3SQ Lead Inspector Val Sevier Unannounced Inspection 27th June 2008 10:00 1 Sheepfold Avenue DS0000014264.V365146.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 1 Sheepfold Avenue DS0000014264.V365146.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. 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1 Sheepfold Avenue Address Rustington Littlehampton West Sussex BN16 3SQ 01903 785753 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) H4M042mellor@mencap.org.uk www.mencap.org.uk Royal Mencap Society Ms Josi Mellor Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only persons aged between 18 and 65 years may be accommodated Date of last inspection 23rd August 2006 Brief Description of the Service: 1 Sheepfold Ave is a care home registered to provide personal care support (PC) and accommodate up to six service users with a learning disability (LD) between the ages of eighteen and sixty-five. It is a detached property located within a short distance from Angmering and Rustington. The property provides accommodation consisting of all single rooms, lounge, dining room, sensory room and easy access to the garden at the rear of the property. The service provides personal care assistance to service users who have a profound learning disability and physical disability. Support and assistance is also provided to enable service users to access facilities and activities at home and in the community to ensure they lead an active lifestyle. The Royal Mencap Society owns the service. The Responsible Individual operating on behalf of the organisation is Ms Janine Tregelles. The Registered Manager responsible for the day-to-day running of the home is Ms Josi Mellor. Fees for the service range from £840.36 to £1446.20 depending on assessed needs of the individual. 1 Sheepfold Avenue DS0000014264.V365146.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 3 star. This means the people that use this service experience excellent quality outcomes. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards and Regulations. The findings of this report are based on several different sources of evidence. These included: the Annual Quality Assurance Assessment (AQAA) completed by the home, and an unannounced visit to the home, which was carried out on the 27th June 2008 during which we were able to have discussions with the manager, staff and have interaction with some of the people that use the service. During the visit we looked around the inside and outside of the home, which included a sample of bedrooms and bathrooms. Staff and care records were sampled and in addition to speaking with staff and people at the home, their day-to-day interaction was observed. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection. What the service does well: The home welcomes people who will use the service and their families or representatives, to visit the home and assess the facilities of the home. The manager actively seeks information from external healthcare professionals as part of the assessment where necessary, to ensure that the home is able to meet assessed needs. People who live at the home receive good support for a wide range of needs, which can be challenging both to them as individuals and to the staff. The staff are able to provide a good service because it is based on their knowledge, experience and training. This is supported by the detailed care plans and other written documentation, which have been agreed by the individuals or their representatives. People moving into the home are assured that the home that they are entering will meet their needs. For example, staff are well trained and show perception and professionalism in the way they deliver care, which enables people who live at the home to feel safe and enjoy a varied and companionable way of life. Staff treat people who live at the home with respect; they share their companionship and give support sensitively. Detailed records were in place that gave staff information that enabled them to provide the help that individuals needs and encourage risk taking as part of daily life activities. 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 6 Health care was promoted through the use of tools that assist with monitoring the nutritional needs of individuals when that was necessary. The home has also developed good working relationships with healthcare specialists. Daily routines in the home were flexible and people who use the service being encouraged to make choices for themselves and exercise personal autonomy as far as was reasonably possible. People who live at the home were positive about the food that the home provided and were pleased with the range of activities in which they could participate and the condition of the accommodation that they occupied. People at the home, relatives and staff had confidence in the effectiveness of the home’s manager. Systems and procedures in the home worked well including, dealing with complaints, quality monitoring, and health and safety. The residents are encouraged to communicate freely about how they feel and what they want. The staff appear to be supported by the manager and the company to meet the support needs of the people who use the service. What has improved since the last inspection? What they could do better: There were no requirements for action made as result of this visit that are dependent on the manager and staff at the home. However the Registered Provider must carry out regular monthly visits to the home and a record must be available at the home that documents this visit. 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 7 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. 1 Sheepfold Avenue DS0000014264.V365146.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 1 Sheepfold Avenue DS0000014264.V365146.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 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People that use the service can feel assured that their needs will be assessed and that the service has an understanding of their needs using the assessment process. EVIDENCE: One person has moved to the home since the last inspection and a second returned to the home following a spell of time in hospital following surgery. We looked at the assessment process and how the home enabled the individual to move to Sheepfold Avenue. The AQAA received from the home said: “As a service provider organisation, we place great importance on supporting people and their families in making an informed choice about where and how they live. We have policies and processes that guide staff in ensuring that people receive good and reliable information before they move, and are supported in making a successful transition. We have an assessment process that involves gathering information from the person we are supporting, people who are important to them and any other professionals involved in their support (including assessments completed by care management). 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 10 Our Families’ Charter clearly outlines the way in which we wish to work with families in the best interests of the person we are supporting. It enables us to share information and insights, in order to help us meet an individual’s needs. We also recognise the importance of carefully reviewing that someone’s needs can be met by the service, and once we are providing a service to someone we have regular planned reviews to address any issues or changes that have been identified. As a Mencap service we ensure any admission process is comprehensively completed, this is evident in our Corporate Assessment Process devised for our area. We also devised an individual Assessment Process Pack for this service. This depicts planned visits to the service with a gradual increase of duration and time spent in the service for the individual. Opportunities were set up to meet and engage with other service users, not only in the home but also in the community to integrate the individual in meaningful activities. Opportunities to get to know the staff team, opportunities to use various forms of public transport, risk assessing individual’s needs and abilities whilst in the community prior to admission. Individual input to view potential bedroom and be involved in any decoration to the individuals taste and wishes and needs prior to admission. We also have a section to record what we could do better. We also pull on other professionals for their knowledge in specific areas, for example Seeability, and specialist service to support, inform and share ideas, understanding of needs and potential barriers”. What we found supported this statement by the home. The individual whose assessment we saw had lived at the home previously and remembered the layout of the home. However when they moved in they were in a different room the old bedroom was being used as an office. The individual had some difficulty orientating themselves especially at night due to their poor sight. The manager and her team decided to changed the rooms about moving the office so that the individual could reoccupy their old room, which was also opposite the bathroom. The documentation showed the decision making process and what had led to this decision. The moving across from one home to another took about six weeks, we saw that once it was decided that the individual was moving to Sheepfold Avenue, an action plan of gradual socialising, integration and interaction was made. The date, planned activity, what will be offered from the visit, what will be assessed, who will be present and which staff were to take the lead. These activities included, lunch at the home, bowling with other people who use the service, overnight stays and risk assessments of the individual using public transport. Records were made to inform colleagues for example “be aware to risk assess for homes vehicle”. 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 11 The manager explained that the visits were to assess the interaction between the individual and those living at the home and the impact of the change in the group dynamics of the home. Staff spoken with on the day said it had worked well and that the slow process enabled a smooth transition for all. 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 12 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service receive the level of support and guidance they need in order to meet their specific requirements, with staff giving information to enable the individual to make decisions and understand their care plans. People who use the service are supported to take risks in their daily lives. EVIDENCE: The AQAA stated that: “As a service provider, Mencap’s vision is a society where all people with a learning disability are valued equally, listened to and accepted and our support to people is developed on this basis. We support people to take a lead in their own support planning and help to arrange individual meetings on a regular basis to review these plans. We provide support to make sure key people are invited, enabling the people we support in the development of their plans. Where the development of plans identify that there is a change in the support that someone needs, we make sure that we have informed them what this means for them, and work with them to implement these changes”. 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 13 There was discussion with the manager at the last visit about the clarity of the care plans. It was seen on this visit that the care plans gave instructions on how staff could best support the needs of the individuals at the home. We found that the care plan is referred to daily with a record of activities that the individuals carry out as part of their plan. This file contains the views of the individual their life story, what they hope to achieve, goals and ambitions and the assessment by their key worker. It also contains their progress. The people who live at the home, are closely involved in all aspects of life at the home, where more rigid frameworks are required for the well-being or safety of an individual, for example these instances are identified, recorded, agreed and reviewed. Care plans seen gave examples of how staff support decisions such as supported to use a telephone to keep contact with relatives and friends. One individual has been offered an operation to improve their sight it was seen that the individual has been involved in the decision making process and that capacity is established at stage. Risk assessments were in place for all three individuals who live at the home. These documents set out the assessed hazards to individuals and action to minimise the risk of harm for example: personal care needs, manual handling assessment, wheelchair assessment, travelling in a vehicle, going on holiday, attending activities, swimming/hydrotherapy pool, fire evacuation and daily activities. 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 14 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 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are supported to fulfil their personal development and leisure activities, which are based on their individual abilities and aspirations. People who sue the service are supported in the preparation and choice of their meals, with specific dietary needs also being addressed with encouragement to carry out these tasks on their own. EVIDENCE: Individuals are supported to take part in a range of educational and leisure activities in the community for example local day services and college courses and sessions at a local garden centre. It was also seen that there are regular ‘house’ meetings when the people who use the service and staff discussed this year’s holiday, some are going to Lewes East Sussex and the New Forest. 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 15 Individuals are supported to keep in touch with family and friends, with support provided to go to visit relatives and well as people being visited at the home. People at the home participate in the complete household jobs, such as cleaning and cooking, and any support they need to carry out these tasks is recorded in their care plans. The home has a planned menu that takes into account the likes and dislikes of service users and provides a varied and balanced diet. The kitchen was well stocked with a variety of good quality food. Mealtimes are variable depending on the individual daily activities of the residents. Residents are able to have their meals or snacks where they wish. Staff may join the residents for meals and the group tries to meet up once a day to ‘catch up’ on what has been happening. Individuals are supported to cook/prepare their own lunches with the tea time meal being more communal, although individual choice was evident with alternatives being prepared. The notice board has both pictures and words describing the day’s events and what is available for meal times. These observations supported the AQAA, which said: “Our families’ charter encourages and guides our staff in supporting people to maintain and strengthen family connections that are important to them. As part of a person centred approach to support planning, we actively encourage the people we support to be “health aware” and provide support in healthy eating and lifestyles, particularly where someone has identified a need or wish to improve their health. We encourage and support Service Users to maintain a healthy life style, take regular exercise, programmes and risk assessments where necessary are individually devised according to need. Staff use the sensory room in the service to support music, sensory and quiet time for example. Service users use the resource freely and independently and with each other/ and or with staff. Other activities are available such as cooking, trips out to various events, use of the local community facilities, church, restaurants, post office, bank, etc. Family contact is very much promoted and supported, family members regularly visit the home, individuals are supported to meet family members in the community to eat out, family occasions, attend church services, supported on day trips with family members etc. We provide transport for the Service Users to attend day services and other activities. We also use and promote public transport, in particular trains, as this experience appears to be enjoyed and requested more by some individuals. Buses are also used, but not as frequent as the train. Managing Risk (risk assessments for these various modes of transports are individually in place). Each Service User is offered a choice to participate in activities/ opportunities and their choice to decline is respected if they so wish to”. 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 16 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 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and emotional needs of people who use the service are known, well met and reviewed with evidence of good multidisciplinary working taking place on a regular basis. EVIDENCE: We were able to see from care plans and from discussion with staff and the manager that needs are being met. The individuals at the home have a wide range of needs, including mental health difficulties and/or physical needs including poor sight. People who use the service have access to GP’s, community psychiatric nurses and other healthcare services such as opticians, dentists and chiropody. Care plans seen at the visit have detail on how mental and physical healthcare needs are identified and met. The manager was able to show that she had invited social services to reviews, however they did not often attend, it was seen that other professionals who work with the home in the care of the individuals have attended the reviews. 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 17 It was seen that a review had taken place of the action requested from the last review and a new action plan made for the forthcoming year. For one individual who has deteriorating sight it was seen that other professionals and support was available and been sought for example booklets from the Royal National Institute for the Blind (RNIB), which explain what happens when you go into hospital for an eye operation, the books are in large print and picture format. There was evidence that both Seeability and RNIB are involved with the ongoing care and support for the individual and in the planning of the hospital admission. The home uses a monitored dosage system arranged with a local chemist. Medication records and storage were seen and were appropriate to the needs of the residents and in line with the homes policy. Regular checks of stock are undertaken by staff to ensure that there is no over ordering and that medication remains in date. Medication is stored in a locked cupboard and records relating to administration of medication had been fully completed. Most staff have completed medication training and have regular updates through distance learning and on site training. There was a photograph of each individual person who uses the service with a pen picture of their medication what it is, why it has been prescribed, when it is to be given, how and the side effects. A copy of health appointments with the doctor or other healthcare professional, their advice and prescriptions were seen in the medication file. There was information supporting staff in administering medication as in one case one individual prefers one member of staff, there were instructions on what to do if the individual refused for example seeking colleagues support. The AQAA for the home said:” As part of person centred planning we aim to support people in being more aware of their health needs and use health action plans to support people in doing this. This is not just about physical needs, it also means helping people to feel good about themselves. Our policies and processes around medication actively encourage our staff to demonstrate safe working practices and to fully involve the person in taking as much control as possible over their medication. When we support someone in administering their medication, we develop and use pen pictures to inform our understanding and practice about their specific needs. All staff are trained in the safe handling of medication, this is internally monitored and assessed by the RHM and also externally accredited. All staff spend time with colleagues shadowing the administration of medication and spend time with management going through the policies and procedures, prior to taking responsibility for the administration of medication”. 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 18 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are protected through the open complaints process and the staff’s knowledge and understanding of safeguarding adult issues. EVIDENCE: We spoke with the manager and staff, who confirmed the way they ensure that people who use the service views are listened to is to communicate in the style and pace appropriate to the individual, spend one to one time with individual’s, arrange regular review meetings, form positive relationships with families, friends and outside agencies. It was seen that the way in which staff communicate with individuals was recorded on their care plans. The home has a complaints procedure available, which sets out who will deal with a complaint and how long the provider will take to respond to a complaint. The homes complaints procedure was seen to be available in the information given to people who use the service in both written format and pictures. There have been no complaints received by the home or the commission since the last inspection visit in 2006. The manager advised that the home promotes an open door approach to relatives and people who use the service, to help resolve complaints and issues effectively. The home uses the West Sussex safeguarding adults policy and staff were seen to have training in adult protection as part of their induction as well as regular updates. 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 19 Any concerns raised by people who use the service, staff, relatives or others, have been recorded with action taken, staff are aware of the adult protection policy and whistle blowing. Whilst we were at the home the manager had become aware of concerns by staff of bruises found on an individual, after initial investigations at the home and a discussion with the day centre manager, the manager at Sheepfold Avenue contacted their safeguarding adults person at social services, and logged all information and began her investigation under social services policy guidance. This supported the AQAA from the home, which said: “It is our belief that those who use our services, should be able to comment or complain if any aspect of our services or activities do not meet the high standards that they have a right to expect. Our policies and processes around feedback and complaints actively encourage all our staff to be receptive and respond positively to any identified shortfalls. We have built feedback and complaints into our quality assurance framework to ensure that we act on feedback and learn from this. As a Mencap service we annually update staff on adult protection. Manager has briefed teams on Safeguarding Adults ad reporting Alert procedure; in house file has been complied for teams to refer to. Staff have a brief statement in relation to Safe Guarding Adults in their individual support/ supervision notes. Service Users, families and other professionals are encouraged to comment on good practice and bad practice. Manager actively promotes and expects staff to promote awareness, recording and reporting procedures. We have a comprehensive compliments and complaints procedure and are currently extending this to a more robust and behaviour led feedback and complaints management system”. 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 20 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have a pleasant, safe and homely environment to live in. EVIDENCE: The AQAA received from the home said that: “We aim to work constructively with the housing provider to ensure that the environment is properly maintained, decorated, equipped and furnished to a comfortable standard. Our policies and processes ensure that staff undertake all required tasks and duties to promote and achieve safe working practices and support people in being aware of the need for safety within the home. We aim to encourage and support people to be involved in the upkeep of their home and to take pride in where they live”. We found that there are good internal and external facilities. Communal areas enable individuals to have space, comfort and privacy. The home was clean 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 21 and well maintained and the manager reported that she was able to access money to repair and replace items when necessary. All individuals who live at the home have access and use of the kitchen and laundry and they are supported to be as independent as they can in their own care and daily household activities. The bedrooms seen were brightly decorated and had evidence of individual personalities with posters and the individual’s photographs on the walls, and other personal effects. People who live at the home are encouraged to furnish the room with personal belongings such as furniture and pictures, to make it feel like home. The lounge area had a selection of chairs in different heights and fabrics and each individual had their own chosen chair which in one case was a recliner to assist them to sit comfortably. It was seen that the communal areas also have individual’s pictures and belongings in them. The manager stated that new carpets have been ordered for the stairs halfway and lounge. We also saw that there is negotiation for new handrails to be fitted outside the front door. The manager explained that there are plans to alter some of the borders to enable raised garden areas for the people that use the service to plant their own flowers in. 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 22 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the services have their needs met by staff who are trained, supportive and sufficient in numbers. People who use the services are protected through the home’s current recruitment procedure. EVIDENCE: The AQAA we received said that:” Our policies and processes in recruitment and training, guide and inform effective recruitment practices that include thorough pre -employment checks, induction and on-going training to ensure that staff fully understand their responsibilities and how to effectively support people with a learning disability. Our policies and processes around supervision, attendance and performance review actively encourage a supportive but focussed approach to staff performance and development within the service. As a Mencap service we offer good recruitment procedures, new induction programmes have come into effect as of October 2007 making the Induction by the manager more service appropriate to the new member of staff”. 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 23 We looked at the records of the most recently recruited staff and found that they contained all of the information and checks required. Staff spoken with said they felt there are sufficient staff on duty at all times. Staff complete the skills for care induction which includes: values, understanding the organisation and the role of the worker, health and safety for example fire and incidents, communication for example call bells and methods of communication, abuse and neglect and developing as a worker. Staff have undertaken training in first aid, fire safety, health and safety, food hygiene, moving and handling, safeguarding adults and medication. 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 24 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service benefit from a well run home; with systems and procedures in place which monitor and maintain the quality of the service provided and promotes the safety and welfare of everyone living and working in the home. EVIDENCE: The manager has been at the home approximately four years; she has the NVQ level 4 in care and the registered manager’s award. The registered provider completes monthly visits to the home and makes a report of his findings, including an action plan to address any deficiencies. The last recorded we could see was October 2007. 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 25 The home has a development plan and regularly consults with service users, including an annual survey. The manager has implemented weekly quality assurance checks, to ensure that the service is continuing to meet the needs of people who use the service. The key worker system has changed with the key worker producing a monthly report on the well being of the individuals they care for. The bedrooms have been changed so that they are ergonomic to individual needs. A letter is sent out quarterly to the families or representative of people who use the service with information on staff achievements, changes, the family charter, information about the home – redecoration of the kitchen for example, and how to complain or compliment. We saw that the manager has completed training in the Mental Capacity Act, as have most of the staff at the home. This was seen to be in place for areas where the individuals using the service may wish to look after aspects of their lives for example money and finances. The home does look after all personal monies and it was seen that there are individual accounts and receipts for spending. In May 2008 MENCAP sent letters to all people who use the service and or their representatives and placing authority, advising them that as of the 1st June 2008 they will charge 40 pence per mile on social and leisure travel (not day care or health appointments). During the inspection visit, it was clear from observation and sampling records such as care plans, that individual needs were identified and individual programmes of care were agreed and in place, with needs and aspirations being an important part of their personal development. The manager had completed the AQAA and returned it the commission, which detailed that all necessary safety checks and associated certificates were in place. This information was sampled and it was found that a file is maintained in which such safety certificates/information are kept. The manager was confident that all safety checks have been carried out. There was evidence of risk assessment procedures being in place and training standards are such that the vulnerabilities of residents are known and addressed in operational activities. The AQAA also stated the improvements since the last visits and planned areas of development for the coming year. Regular checks are undertaken of the fire equipment and staff were seen to have had their training every six months. The local fire officer had been to the home in February 2008 and revisited in June 2008, the home has been given three months to investigate alternative door closure systems. This supported the AQAA sent by the home which said:” As a service provider, Mencap has a Continuous improvement framework that sets out how we 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 26 promote and assure the quality of service to the people we support. This begins with the way we work with people everyday using person centred planning. We also have clearly defined processes for gaining feedback from service users and stakeholders, meeting our compliances, monthly monitoring visits and annual reviews of the service. We recognise that the manager of the service needs to ensure that the activities within the service achieve a balance of creating an environment where the people we support feel both safe and secure and empowered to achieve the things that matter to them. As a Mencap service we endeavour to manage ensure the correct records and reporting procedures are in place, relevant checks are adhered to”. 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 27 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 4 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 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 4 X 4 X 3 X X 3 X 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 28 No 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 YA39 Regulation 26 (1) (2) (3) (4) (5) Requirement The registered provider must undertake monthly visits to the home and a report of the visit must be available at the home, identifying areas of concern or that are working well in the service given to people living at the home. Timescale for action 27/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 1 Sheepfold Avenue DS0000014264.V365146.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 1 Sheepfold Avenue DS0000014264.V365146.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. Re-publishing this information is in breach of the terms of use of that website. 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