Inspection on 24/10/07 for 1 Sheppard Close

This inspection was carried out on 24th October 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 Sheppard Close 06/09/06

1 Sheppard Close 07/11/05

1 Sheppard Close 25/05/05

1 Sheppard Close 29/01/05

1 Sheppard Close 26/08/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 1 Sheppard Close Devizes Wiltshire SN10 2BT Lead Inspector Tim Goadby Key Unannounced Inspection 24th October & 1st November 2007 17:05 1 Sheppard Close DS0000028293.V350344.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 Sheppard Close DS0000028293.V350344.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 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 1 Sheppard Close Address Devizes Wiltshire SN10 2BT 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) 01380 725133 www.care-ltd.co.uk CARE (Cottage and Rural Enterprises Ltd) Post Vacant Care Home 7 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1) of places 1 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Only the service user referred to in the application dated 30 November 2005 may be accommodated in the home under the category of registration: Learning disability, over 65 years of age. 6th September 2006 Date of last inspection Brief Description of the Service: 1 Sheppard Close is run by the registered charity Cottage and Rural Enterprises Ltd (CARE). The service provides care and accommodation for up to seven adults with a learning disability. The property is in a residential area of Devizes, a short walk from the town centre. The accommodation includes a self-contained flat on the ground floor, which can be occupied by one service user. The remainder of the ground floor contains a lounge, an open plan kitchen and dining area, and a separate utility room. The other six service users have their own bedrooms on the first floor of the main part of the home. There are also two bathrooms for general use. During the week, service users attend the day facilities at another CARE establishment in the nearby village of Rowde. They may also access other activities, such as college courses. 24 hour support is provided by a management and staff team, although some service users are independent in some activities and personal routines. Information about the service, including CSCI inspection reports, is available both at Sheppard Close and at CARE’s larger nearby project in Rowde. Information can be made available to people in different formats to meet particular individual needs. 1 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was completed in November 2007. The process included a review of any information received about the home since its last main inspection, which was in September 2006. For this key inspection we asked the home to complete an Annual Quality Assurance Assessment (the AQAA). This document contains key information about the service, as well as their own judgements and evidence about how well they are doing in all areas of service delivery. We also sent out survey forms. We received replies from six service users, three relatives and three members of staff. An unannounced visit was made to the home on a weekday evening, to meet service users. This lasted three hours. A return visit took place by appointment the following week, to meet the home’s senior staff and conclude the inspection process. This lasted just over two hours, concluding with a short visit to CARE’s main site at Rowde to view some records held there. The fieldwork at the visits included sampling of records, discussions with service users and staff on duty and a tour of communal parts of the home. After the inspection visits we had telephone conversations with a relative of a service user and with a local senior manager representing CARE. The judgements in this report are based on all the above sources of evidence. What the service does well: Service users appear settled and satisfied with living at Sheppard Close. Six of them completed survey forms for this inspection. With one exception, they raised no concerns. Most service users were also present when we visited the home. They appeared happy in their surroundings. They were at ease in their interactions with each other, with staff on duty and with our visit. Service users are able to exercise choice and independence. They have a lot of flexibility in how they spend their time at home. Where able, they also access local community facilities independently. Feedback from relatives of one service user praises the approach of the service in encouraging greater independence and the development of potential. 1 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 6 Service users benefit from the support of well trained staff. CARE has its own training co-ordinator, based in Rowde, who oversees this area. All employees undertake a range of courses relevant to their job roles. This includes achieving nationally recognised qualifications in care. There is a strong focus on providing activities and outings. Service users have regular contact with the local community and the opportunity to pursue a wide range of leisure interests. This enhances the range of experiences available to service users, promoting their quality of life. Service user involvement is promoted in all areas of service delivery. Each individual can contribute to planning their own care and also has the opportunity to be involved in groups making decisions about other aspects. 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. 1 Sheppard Close DS0000028293.V350344.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 1 Sheppard Close DS0000028293.V350344.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have their needs assessed and make a positive choice about moving into the home. EVIDENCE: The home had an admission in February 2007. This service user transferred to Sheppard Close from another CARE establishment within Wiltshire. The assessment process for possible admissions to the home takes a minimum of one week. Referrals to CARE may stay in a short-term placement at Rowde for the purpose of assessment. A decision can then be taken about which of the organisation’s homes may be most suitable for the person. When there are vacant places at Sheppard Close, service users currently living at Rowde may have the opportunity to be considered for them. This is because such a move represents a next step towards greater independence. Equally, referrals from elsewhere may be considered. Service users already living at Sheppard Close are involved in decisions about anyone who may move in. Prospective service users visit the home and spend time with its current residents, for instance by staying for a meal. 1 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 9 The changing needs of existing service users are also kept under review. Any possibility of individuals moving on to other settings is discussed with all relevant persons. This involves the service user themselves, where possible; their relatives; and other key professionals who have input to their care. 1 Sheppard Close DS0000028293.V350344.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 a visit to this service. Service users have their abilities, needs and goals reflected in their individual plans. Service users can make choices and decisions in their daily lives, and about the conduct of the service. Service users are supported to take positive risks and access new opportunities, as part of an independent lifestyle. EVIDENCE: Two sets of service user records were viewed during this inspection. Both have information on all the relevant strengths and needs of each individual. They show evidence of regular review, especially on any topics of particular concern. Other agencies and professionals are involved as appropriate. Service users sign their own care plans along with their staff keyworker, to show that both have been involved in developing them. 1 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 11 CARE has introduced person centred planning for all its service users. This is in line with national good practice developments in the learning disability field. It helps to ensure that a service user’s care focuses on their own wishes and goals. One of the service users showed us their folder, which they have been directly involved in developing, and which they keep in their own room. Service users have individual meetings to work on their own plans. The format used by CARE has been simplified. It is also hoped to make use of pictures and videotape to enhance the accessibility of the plans. This will make them more personal and meaningful than written documents. Service users’ choice and autonomy are promoted in the daily conduct of the home. For instance, service users answer the door and take telephone calls. All six service users who completed survey forms indicated that they are involved in making decisions in the home. Risk assessments and management strategies are used to make judgements about whether service users are safe to undertake activities such as going into town independently, or being left unsupervised at home for set periods. Feedback from relatives of service users was mixed. One felt that the home encourages people to gain more independence and therefore to enjoy a greater quality of life. However, another had an opposing view, feeling that the home does not take enough steps to motivate service users to lead active lives. 1 Sheppard Close DS0000028293.V350344.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 good. This judgement has been made using available evidence including a visit to this service. Service users are provided with a range of activities and opportunities, offering them full engagement with their local community. Service users are able to maintain and develop appropriate relationships with family and friends. Service users’ rights and responsibilities are upheld, balanced with appropriate steps to safeguard their welfare. Service users are offered healthy, nutritious and enjoyable meals, in line with individual needs and preferences. 1 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 13 EVIDENCE: This inspection included an early evening visit, as this is when service users return to Sheppard Close after being out during the day. Service users are relaxed and comfortable in the home, interacting with each other and with staff on duty. They spend time in their own rooms and also some time together in communal areas. For instance, the whole group shared their evening meal. CARE has day service facilities at its nearby project in Rowde. This offers a range of opportunities, including arts and crafts, gardening and information technology. Service users who had been to Rowde on the first day of our visit told us that they had taken part in sessions including knitting and baking. Many of the service users at Sheppard Close spend much of the week at Rowde. However, people are also able to attend other activities if they choose. For instance, one service user regularly attends a couple of social clubs each week, and also has a session at the gym at Devizes leisure centre. Some older service users have reduced the number of hours they spend at Rowde. Service users regularly access community facilities. Some do so independently for local trips. For instance, some service users catch the bus to Rowde. Service users also have outings further afield and holidays. Photos on display in the home show some of these trips. Service users spoke about how much they enjoyed them. Holidays are booked in line with their known interests. People attend various clubs and activities, which reflect their hobbies. One service user is keen on railways and goes to a club for people who share this interest. Another regularly goes riding, and showed us various awards they have gained over the years. The same individual showed us a certificate gained for an exercise and fitness programme. One service user who is keen on gardening has grown vegetables which have been used by the home. At home service users can spend their time relaxing in various ways. There is a computer with internet access which is kept in the lounge for general use. A number of service users enjoy spending time on this. Some were doing so on the evening we visited, looking at websites on topics that interest them. All six service users who completed survey forms indicated that they feel there are good activities for them. All service users who live at Sheppard Close have varying degrees of family contact. Some spoke about recent visits to stay with relatives. Families usually participate in review meetings as well. Service users also keep in touch through letters, phone calls and e-mails. 1 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 14 Service users also have other friendships with people who live locally. One service user indicated in their survey form that they are unhappy about restrictions on contact with a key person in their life. However, this is a known situation. It has been discussed with relevant agencies. Clear guidelines are in place. The service user has consented to these, with reservations. The individual is also receiving positive support, through relationship counselling. The other five service users who completed survey forms all indicated that they like living at Sheppard Close. Three sets of relatives completed survey forms. Two of these are entirely satisfied with arrangements for keeping them informed about relevant issues in a service user’s life. The others raised a number of concerns about topics where they feel communication has not been effective. These relatives have also raised concerns with CARE, who are in the process of responding to them. All service users contribute to choosing the menu for the home. There are no particular dietary needs amongst the current group. The service aims to promote suitable variety and encourage healthy eating where possible. Mealtime arrangements at the home have changed recently. Service users used to have a main cooked meal during the day whilst at Rowde. But now they take packed lunches and have their main meal at home in the evening. All service users are able to make their own drinks and snacks independently. Each helps to make their own packed lunch in the evening, ready for the following day. They also regularly help with shopping for groceries. Some may participate to a degree in the preparation of cooked meals. The ground floor flat has its own kitchen, which gives one service user the opportunity to be more independent if they wish. But anyone occupying the flat is still welcome to join the main household for meals if they prefer. Five service users indicated on their survey forms that they like the food at Sheppard Close. The other put that they sometimes do so. 1 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to address their personal and health care needs effectively. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Records show that service users access regular health checks, including appointments with specialists such as dentists and opticians. Any developing issues of concern are also followed up. Staff give support as necessary. The personal and healthcare needs of the group at Sheppard Close are increasing as they get older. This is recognised within individual service user plans and within overall service planning. Issues such as the suitability of the environment and the appropriateness of staffing levels are kept under review. All six service users who completed survey forms indicated that they feel well cared for and that their privacy is respected. 1 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 16 Two sets of relatives indicated in survey forms that they believe the quality of health and personal care at Sheppard Close is very good. One wrote that the home “shows great concern for the well-being” of its service users. Relatives of one service user raised a number of concerns where they feel that there have been deficiencies in health and personal care, dating back over a number of years. These are issues which they have also taken up with CARE directly. The organisation was in the process of responding to them. Service users’ ability to manage their own medication is risk assessed. At this inspection most service users had only limited responsibility in this area. Staff were providing full support in most cases. All staff working at the home receive training in the administration of medication. When errors have occurred, these have been reported appropriately and suitable actions have been taken to review practice. This minimises the risk of the same mistakes happening again. Arrangements for the storage and recording of medication were observed during this inspection and seen to be appropriate. Administration was not directly witnessed, but the arrangements were discussed. Some service users are not directly observed when taking medication, as they prefer to take it privately and then confirm that they have done so. Such arrangements are clearly set out in individual records, so that it is also clear what the entry in medication administration records denotes. The pharmacist supplying medication to the home also visits occasionally to check arrangements and give advice. The most recent such visit took place only a couple of weeks before this inspection. 1 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are safeguarded by the service’s policies and procedures for complaints and protection. EVIDENCE: The service has a complaints procedure. Records are kept of issues raised, and of actions taken in response. Complainants get a feedback form, so that they can say if they are satisfied with how the service dealt with their issue. Complaints information is displayed in the home, with CSCI contact details. Informal concerns are logged, as well as more serious complaints. All six service users who completed survey forms indicate that they feel safe at Sheppard Close. They also know who to speak to if they are unhappy. Complaints are addressed appropriately, including the involvement of other agencies when necessary. Suitable actions have been taken in response to the findings of investigations. 1 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 18 Relatives of one service user raised a number of concerns in the feedback they gave to us. They have also raised the same issues with CARE. The organisation was in the process of addressing these. We discussed with one of CARE’s local managers how they are doing this. The approach taken was suitable in trying to strike a balance between the legitimate concerns of the relatives and the rights of the individual service user. CARE has suitable procedures for safeguarding vulnerable adults. It also works within the local multi-agency arrangements. Issues have been referred to this process when necessary. This has helped to identify agreed strategies for managing known risks for some individuals. All staff receive training about abuse and protection. 1 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a clean, comfortable and safe environment, which is suitable to meet their needs. EVIDENCE: Sheppard Close is a recently built property in a residential area of Devizes. It is a few minutes walk from the town centre. The home also has its own vehicle, which helps service users to access a range of local amenities. One portion of the ground floor is a self contained flat, which can be occupied by one service user. This has a bedroom, sitting room, kitchen and bathroom. It allows the opportunity for one person to practice living more independently, whilst still having access to constant staff support. 1 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 20 The other six service user bedrooms are on the first floor. As the current group is three males and three females, they have been allocated rooms on the two sides of the building. Each side also has a bathroom for general use. Future development plans include providing en-suite facilities for service users. Downstairs there are communal rooms, consisting of a lounge, and a kitchen with dining area. There is a separate utility room, containing laundry facilities. There is also a ground floor toilet. Staff accommodation is on the first floor, with one room serving as an office and sleep-in area. This also has an en-suite bathroom. Access between the two floors of the home is by stairs only. There is an enclosed garden at the rear of the home. This has been mainly laid to gravel, so it is low maintenance. The home was clean and hygienic in all the areas seen during this unannounced inspection. Service users participate in household tasks, in line with their abilities and preferences. For instance, on the evening we visited they cleared away and washed up after the main meal. One person was also assisted to sort out their laundry and do some ironing. 1 Sheppard Close DS0000028293.V350344.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, 33, 34 & 35 Quality in this outcome area is good overall, although quality in the area of staff recruitment is only adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by suitable numbers of appropriately trained staff. The home needs to ensure clear evidence that service users are protected by effective systems for the recruitment of staff. EVIDENCE: The home’s staff team now consists of five permanently allocated members, providing a total of 160 hours per week, not including overnight sleep-in cover. Staff cover is based around the needs of the service users. There is always at least one staff member present whenever anyone is at home that requires support. Sometimes there will be two staff on duty, for times when more service users are at home, such as weekends. This enables greater flexibility about what activities can be undertaken. When necessary, shifts are covered from CARE’s pool of relief staff, or by staff provided by agencies. 1 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 22 Overnight cover is provided by a staff member who sleeps in at the home. There is also an on-call rota of senior staff within CARE locally, who can be contacted for advice and support if necessary. Feedback from staff surveys includes comments that they would like more opportunities for one-to-one support to service users. The home’s deputy manager said that this situation should improve now that they have more staff. The service also intends to conduct an overall review of its staffing arrangements, to ensure that these remain in line with the changing needs of service users. For instance, as service users get older some of them are spending more time at home. This affects what staff cover is needed. There is an extensive range of training available to all staff. This is overseen by a training co-ordinator, based at Rowde. New staff have a six week induction programme. The first two weeks are spent being introduced to key policies and guidelines, and shadowing other staff on shifts to observe care tasks. New starters also receive a handbook of relevant information, including national codes of conduct for social care staff. Induction is carried out in accordance with the national framework for staff working in learning disability services. CARE participates in a scheme within Wiltshire where different organisations act as markers for each other’s staff. This leads on to staff undertaking National Vocational Qualifications (NVQs) in care. Over 50 of the current care team at Sheppard Close have achieved this award at Level 2 or higher. Senior staff have the opportunity to go on to take the qualification at a management level. There is an overall training plan for the service. This includes defining what training is needed for each post. There is a range of mandatory courses that all staff undertake, with more training required for more senior roles. Individual training records are maintained for all staff. There is also an overall database, which helps to keep the service plan updated. CARE has its own training staff who can deliver many of the courses which are needed. Other sources of training are accessed as necessary. There is a training room on site at Rowde. A particular need for dementia training has been identified at this service, to reflect the developing needs of some service users in this area. Staff who attended courses on this earlier in the year said they found it really useful. 1 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 23 Other training during 2007 has included courses on report writing, physical interventions and driver safety. All six service users who completed survey forms indicated that staff treat them well. The process of staff recruitment and selection is managed locally. CARE has a central human resources department, which generates all necessary policies. Service users are involved in recruitment. This includes participating on interview panels, after receiving suitable training. Some service users told us that they helped with the recent interviews for the newly appointed manager. Staff records for the current team showed that most of the required information was in place. For instance, all staff were checked regarding criminal records and their suitability to work with vulnerable people, before they began working at the home. Records for the most recent appointment only contained one written reference when we saw them, whereas a minimum of two are required. The second reference was forwarded to us after our visit, as proof that it had been obtained, but not filed correctly. 1 Sheppard Close DS0000028293.V350344.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home, and will be further protected once a suitable manager is registered. Quality assurance measures underpin service developments and include actions based on the views of service users. Service users’ health and safety are protected by the systems in place. EVIDENCE: The home’s previous registered manager left Sheppard Close earlier in 2007. The deputy manager has been acting as manager since that time. A new manager, Mr Clive Sandiford, has now been appointed. 1 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 25 Mr Sandiford previously worked for CARE in a senior position. He is now returning to the organisation as home manager at Sheppard Close. He was appointed only shortly before this inspection and was still going through his induction period when we visited. Mr Sandiford intends to apply for registration as manager on satisfactory completion of probation. He will also need to undertake the relevant qualification, the Registered Managers Award. The home’s deputy manager remains in post to help share the managerial responsibilities for the service. CARE also has a number of senior management and administrative staff based at Rowde. They oversee various areas of service delivery, including staff training, health and safety, quality assurance, financial issues and day services. There are regular management meetings covering all these aspects. There is a locality manager for CARE’s Wiltshire services, including Sheppard Close, and clear systems for reporting to the senior levels of the company. Some staff survey forms raise concern that there could be better communication, both within the home and between Sheppard Close and CARE’s main local site at Rowde. However, the manager and deputy express surprise at these views. They feel that a number of good systems are in place. These include regular handovers, a diary and a communication book. CARE has quality assurance systems, which it is in the process of reviewing. The home also completed an Annual Quality Assurance Assessment (the AQAA) for this inspection. This document asks the service to audit its own performance, identifying strengths and also areas for development. The home has told us that its future plans for progress include making information more accessible for service users, continuing to develop person centred planning and providing more flexible support, through a review of staff rotas. Service user meetings take place at Sheppard Close. Larger forums are also held at Rowde. These sessions are at least once a month. Service user representatives then give feedback to staff meetings. Each service user also has regular one-to-one time with a staff keyworker. This is another opportunity for them to raise any issues they wish to discuss. Staff have regular individual supervision meetings, usually around once every six weeks. Staff meetings are held monthly. Service users’ relatives are kept updated at least monthly, usually by phone. A health and safety co-ordinator, based at Rowde, oversees practice in this area. CARE has a range of policies and manuals covering the topic. Sheppard Close also has a staff member who is the designated lead person for health and safety in the home. 1 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 26 There are regular recorded checks on all elements of health and safety. The co-ordinator oversees this process. At Sheppard Close, current records are kept in the house, and then returned for storage at Rowde when complete. Health and safety is also regularly discussed in meetings, and an overall monthly report is produced. All staff receive training in a range of health and safety topics. Any relevant information is circulated to them. Service users also receive training in issues such as the use of hazardous materials. Potentially hazardous substances, such as cleaning materials, are stored safely when not in use. Risk assessments are carried out on a wide range of areas. This includes general topics, and issues relating to individual service users, such as whether or not they are safe to be left at home on their own. Staff who carry out risk assessments are trained in how to do so. External contractors are engaged to carry out various checks and services so that all equipment is maintained safely. Fire safety practices in the home include service users and staff. Records show that the various checks, drills and instruction are all carried out regularly and are up to date. Fire training is provided by a DVD, which staff must watch and then follow up by answering a series of questions. The property has a fire risk assessment. When we visited this dated from November 2006, but was due to be reviewed again later in the month. Actions identified when the assessment was last carried out have been followed up. There is also an individual risk assessment relating to fire for each service user, which addresses their own level of awareness and likely response in an emergency. Service users likely to need extra support are highlighted. The home’s deputy manager did a four day first aid course earlier in 2007 and said that this had proved very useful. 1 Sheppard Close DS0000028293.V350344.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 3 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 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X 1 Sheppard Close DS0000028293.V350344.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 YA34 Regulation 7;9;19 Sch 2 17-2 Sch4-6 Requirement Staff records must contain evidence of all required recruitment checks. Staff records must be available for inspection at all times. Timescale for action 01/11/07 2 YA34 01/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 1 Sheppard Close DS0000028293.V350344.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Sheppard Close DS0000028293.V350344.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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