Inspection on 06/09/06 for 1 Sheppard Close

This inspection was carried out on 6th September 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

1 Sheppard Close 24/10/07

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 Sheppard Close (1) Devizes Wiltshire SN10 2BT Lead Inspector Tim Goadby Key Unannounced Inspection 6 September 2006 17:10 th Sheppard Close (1) DS0000028293.V305002.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 Sheppard Close (1) DS0000028293.V305002.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. Sheppard Close (1) DS0000028293.V305002.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sheppard Close (1) 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) Ms Frances Joselyn Adcock Care Home 7 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (1) of places Sheppard Close (1) DS0000028293.V305002.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. 7th November 2005 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 many aspects of their activities and personal routines. Fees charged to service users range between £510 and £535 per week. 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. Sheppard Close (1) DS0000028293.V305002.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place in September 2006. The evidence gathered included information relating to the CARE organisation which was obtained at the inspection of the larger local service in July 2006; pre-inspection information supplied by the service; six survey forms completed by service users, with support; and four survey forms completed by staff of the home. An unannounced visit to the service was carried out during the evening, to fit with the time when service users are at home. This fieldwork section of the inspection included the following: observation of care practices; sampling of records, with case tracking; discussions with service users and management; and a tour of the premises. What the service does well: Service users appear settled and satisfied at Sheppard Close. All six current residents completed survey forms prior to this inspection visit, and these raised no concerns about the home. All six were also present during the visit, and appeared happy in their surroundings. They were observed to be at ease in their interactions with each other, with the staff member on duty, and with the visiting inspector. They were seen to enjoy a high degree of choice and independence in how they spent their time at home. Where able, they also access local community facilities independently. Staff surveys included positive comments about the effective management of the service, with praise for both the home’s registered manager and deputy manager. They were reported to work well together, to the overall benefit of the service and its users. Staff comments also highlighted a good overall atmosphere at Sheppard Close, with one concluding that it is “a happy place both to work and live in.” The home has a small staff team, which is compatible in terms of age with the service user group, and this contributes to the overall conduct of the home in line with the needs and preferences of its residents. 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. CARE has an effective organisational system for quality assurance. The range of measures used includes obtaining feedback from service users and staff. Service users can be confident that their views contribute to an overall philosophy of continuous service development. Sheppard Close (1) DS0000028293.V305002.R01.S.doc Version 5.2 Page 6 Service users are protected by robust systems for the recruitment and selection of staff. Records show that all required checks are completed before new staff take up post. Service users contribute to the selection process. Once new employees begin work, they have a thorough introduction to the service before they begin hands-on care. There is a strong focus on the provision of 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 the planning of their own care, and also has the opportunity to be involved in groups making decisions about other aspects. Further developments are planned by CARE to promote even greater user involvement and consultation. What has improved since the last inspection? What they could do better: At the previous inspection, there was a requirement to have a suitable fire risk assessment for the property. This has not been met in full. Individual risk assessments about service users’ awareness of fire safety issues are in place. However, there was no evidence of an overall fire risk assessment for the premises. This is required, to address issues such as the particular hazards that may be present, and the measures that are in place to minimise any danger from these. Service users and others are placed at risk of harm by a failure to fully address this issue. Fire safety is also compromised by the inappropriate practice of wedging open fire restricting doors. This places all users of the building at risk of harm, as the doors will not act to prevent the spread of fire if it occurs. Fire restricting doors must only be kept open in normal use by the means of suitable holdback devices, which will automatically ensure the door closes if the alarm sounds. Risk assessments and management strategies for service users are well set out in their individual records. But practice could be enhanced by clearly Sheppard Close (1) DS0000028293.V305002.R01.S.doc Version 5.2 Page 7 documenting who has been involved in agreeing each care decision. This helps to demonstrate that service users are able to participate in key judgements about their own care, and that they have access to advice and input from all relevant persons. Heating levels can be too warm in some parts of the home. This was particularly noted to be an issue in the staff office and sleep-in room. This can impact on comfort levels for users of the building, and also contributes to unsafe practice in wedging doors open. Investigation of suitable ways to alleviate this problem would benefit everyone who spends time at 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. Sheppard Close (1) DS0000028293.V305002.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 Sheppard Close (1) DS0000028293.V305002.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Prospective service users have their needs assessed and make a positive choice about moving into the service. EVIDENCE: The six service users currently living at Sheppard Close have done so since the service first opened around ten years ago, and have been in the care of the organisation for much longer than this. There have been no admissions to the home for some time, but plans are now underway for somebody to move into the vacant ground floor flat. This is a service user who currently lives at the nearby CARE facility in Rowde. The prospective service user knows the current group at Sheppard Close well, having lived in another establishment with them previously. They continue to see each other regularly at their day activities. The prospective service user has also undertaken a number of trial visits to Sheppard Close, including some overnight stays. They have expressed their preferences about how they would like to use the available accommodation, and these wishes are to be respected. Sheppard Close (1) DS0000028293.V305002.R01.S.doc Version 5.2 Page 10 The process of preparing for admission had been delayed around the time of this inspection visit, due to some damage caused to the flat whilst it is unoccupied. (Please refer to the Environment section of this report for further information.) Sheppard Close (1) DS0000028293.V305002.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the 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. Documentation should show who has contributed to risk management decisions. EVIDENCE: There were six service users in residence at the time of this inspection visit. Individual records for two of these were sampled. Both had an appropriate range of key information in place, including up-to-date care plans and risk assessments. There is evidence of service users’ input to their own care, with their signatures on their care plans. Sheppard Close (1) DS0000028293.V305002.R01.S.doc Version 5.2 Page 12 Important information about changes in people’s skill levels is clearly set out. If there have been resulting amendments to care guidelines, the reasoning behind these is explained. For instance, where it has been necessary to reduce the level of independence previously offered to one person, the appropriate reasons for this are included in the record. Risk assessments and management strategies are used to make judgements about whether or not service users are safe to undertake activities such as going into town independently, or being left unsupervised at home for set periods. The records could be clearer about who has been involved in the process of reaching such decisions. CARE locally has begun the process of person centred planning for all its service users. This is in line with national good practice developments in the learning disability field, and helps to ensure that a service user’s care focuses on their own wishes and goals. Two of the service users at Sheppard Close showed the inspector their own folders, which they have been directly involved in developing, and which they keep in their own rooms. Service users have regular individual meetings to work on their own plans. The format used by CARE has recently been simplified, and it is hoped to make greater use of pictures and videotape to enhance the accessibility of the plans. The service intends that this will make them more personal and meaningful to individuals than if they are purely paper based. Service users’ choice and autonomy are promoted in the daily conduct of the home. At this inspection visit one service user answered the door, using an intercom system, and also showed the inspector around. Monthly service user meetings take place at Sheppard Close. Records are kept of these. Service users also participate in some meetings on wider issues to do with CARE locally, which are held at its larger project in Rowde. One person from Sheppard Close attended CARE’s national conference in 2005, and another service user is due to do so this autumn. Sheppard Close (1) DS0000028293.V305002.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the 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. EVIDENCE: This key inspection was conducted over the late afternoon and evening period, as this is when service users return to Sheppard Close after spending their Sheppard Close (1) DS0000028293.V305002.R01.S.doc Version 5.2 Page 14 days elsewhere. People were seen to be relaxed and comfortable in the home, interacting with each other and with the staff member on duty. Service users spent some time together in communal areas, and shared their evening meal. As it got later, people tended to spend time more separately, making use of their own rooms. CARE has its own day service facilities at its nearby project in Rowde. This offers a range of opportunities, including arts and crafts, gardening and information technology. Many of the service users at Sheppard Close spend much of the week at this facility, where they also have a midday meal. 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 service users are able to access the local community independently. For instance, during this inspection one person was out for a time doing some personal shopping. Service users regularly access a range of community facilities. They also have outings further afield, and go away on holidays. Photos on display in the home show some of these trips, and service users spoke about how much they had enjoyed them. Holidays had been booked in line with the known interests of service users. For instance, a group of ladies had been to Yorkshire to visit the set of one of their favourite television programmes. People attend various clubs and activities, which reflect their own hobbies. One service user is particularly interested in railways, and goes to a club with other people who share this. Another regularly goes riding, and showed the inspector the various awards they have gained over the years. One service user who is keen on gardening has successfully grown vegetables which have been used by the home. All service users who live at Sheppard Close have varying degrees of family contact. Relatives usually participate in review meetings. Service users also have other friendships with people who live locally. All service users contribute to choosing the menu for the home. There are no particular dietary needs amongst the current group. The service works with its residents to promote suitable variety and encourage healthy eating where possible. All service users are able to make their own drinks and snacks independently. They also regularly help with shopping for groceries, and 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. Sheppard Close (1) DS0000028293.V305002.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the 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: A sample of two service user records were read. These showed that the home identifies any key issues relating to people’s physical and mental health, and takes appropriate steps to address these. For instance, where there is concern about someone’s overall deterioration, referral has been made to relevant specialists to help assess and monitor this. Records also show that service users are enabled to access regular health check ups, including appointments with specialists such as dentists and opticians. Staff give support as necessary. Sheppard Close (1) DS0000028293.V305002.R01.S.doc Version 5.2 Page 16 Generally the personal and healthcare needs of the group at Sheppard Close are increasing as they get older. There is a recognition of this within individual service user plans, and also within overall service planning. Issues such as the suitability of the environment and the appropriateness of staffing levels are being kept under review. Service users’ ability to manage their own medication is risk assessed. Some of the group at Sheppard Close retain some independence in this area, within agreed guidelines that are set out in their individual plans. Others rely more on support from staff. 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, administration and recording of medication were observed during this inspection, and seen to be appropriate. Some service users are not directly observed when taking medication, as they prefer to do this 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. One service user is taking herbal remedies for a couple of health problems. The suitability of these products, and their possible interaction with other prescribed medicines, has been checked out with the individual’s GP. The home manager has recently completed a course on medication topics, and is now due to pass this learning on to the rest of the staff team. Sheppard Close (1) DS0000028293.V305002.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the 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 any issues raised, and of the actions taken in response. Complainants also get a feedback form, so that they can say if they are satisfied with how the service has dealt with their issue. Complaints information includes contact details for the CSCI. Informal concerns are logged, as well as any more serious complaints received. All six service users indicated on their survey forms that they know how to make a complaint, and who to speak to if they are unhappy about anything. Complaints are addressed appropriately, including the involvement of other agencies when necessary. Suitable actions have been taken in respect of the findings of investigations. CARE has suitable procedures for adult protection, and 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 Sheppard Close (1) DS0000028293.V305002.R01.S.doc Version 5.2 Page 18 known risks for some individuals. All staff receive training about abuse and protection. Sheppard Close (1) DS0000028293.V305002.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users live in a clean and safe environment, which is suitable to meet their needs. Comfort levels could be improved by reducing heating levels in parts of the home. One part of the property will need to be repaired before it can be used as service user accommodation again. 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 taken up by 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. At the time of this inspection visit, the flat had not been occupied for some months. During this time a leak from a bathroom on the first floor had gone Sheppard Close (1) DS0000028293.V305002.R01.S.doc Version 5.2 Page 20 undetected, and the ceiling in part of the flat had finally collapsed, causing significant damage. This was under repair at the time of this inspection, and the flat remained unoccupied. It is anticipated that all damage will be repaired before the area is used for accommodation again. The other six service user bedrooms are on the first floor. As the current resident group consists of three males and three females, they have been allocated rooms on the two different sides of the building. Each of these sides also has a bathroom for general use. In the longer term it is hoped to be able to provide more 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 of this inspection they cleared away and washed up after the main meal. One person was also assisted to sort out their laundry and do some ironing. A comment in staff surveys highlighted that it can be difficult to maintain comfortable heating levels in some parts of the building. At the evening inspection visit it was noted that the staff office and sleep-in room felt oppressively warm unless the door was kept open. Sheppard Close (1) DS0000028293.V305002.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are supported by suitable numbers of appropriately trained staff. Service users are protected by effective recruitment practices. EVIDENCE: Staff cover at Sheppard Close 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. 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. Service user comments included positive feedback about staff. One person wrote on their survey form that “My keyworker is always there when I need her.” Sheppard Close (1) DS0000028293.V305002.R01.S.doc Version 5.2 Page 22 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 of this is spent being introduced to key policies and guidelines, and shadowing other staff members on shifts to observe care tasks. New starters also receive a handbook of relevant information, including the 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 are marking each other’s staff. This leads into staff undertaking National Vocational Qualifications (NVQs) in care. Senior staff have the opportunity to go on to take the qualification at a management level. Sheppard Close has a small staff team. At the time of this inspection, two staff had achieved NVQs, one at Level 2 and the other at Level 3. This meant that the home was above the 50 target for care staff with such qualifications. 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. It is hoped that staff will attend suitable courses over the next few months. There have been no recent appointments at Sheppard Close itself. However, organisationally it has been seen that CARE’s staff recruitment is carried out in line with all the required criteria. Records for this were checked during the inspection at Rowde in July 2006. The sample seen then showed that the full range of required checks had been completed before people started employment. Records seen at Sheppard Close also supported this. CARE has a central human resources department, which generates all necessary policies. The process of recruitment and selection is managed locally. Service users are involved wherever possible. This has included some of them participating on interview panels, after receiving suitable training. Sheppard Close (1) DS0000028293.V305002.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area was generally good. However, practice in the particular area of fire safety was only adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The registered manager is suitably competent and experienced, so that service users benefit from a well run home. 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 in most cases. Service users and others are placed at risk of harm by some deficits in fire safety practices. Sheppard Close (1) DS0000028293.V305002.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager for Sheppard Close is Ms Frances Adcock. She was appointed to her post in 2005, and has successfully completed the process of registration through the CSCI since the home’s last inspection. She is currently working towards the completion of the management qualifications which all registered managers are required to achieve. The home also has a deputy manager, Mrs Beryl Mould. Staff surveys included positive comments about Ms Adcock’s impact on the service. She was stated to be “supportive and caring” and to have helped the home run smoothly. There was also a positive comment about how effectively the manager and deputy manager work together. CARE also has a number of senior management and administrative staff based at Rowde, who oversee various areas of service delivery. These include staff training, health and safety, quality assurance, financial issues and day services. There are regular management meetings covering all aspects of service delivery. 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. CARE has an organisational quality assurance system. One staff member, based at Rowde, is responsible for overseeing the implementation of this locally. The process involves auditing all areas of service delivery, with checks at various frequencies. This includes obtaining feedback from service users and staff. Any actions identified from the quality assurance process are planned in order of priority. Records specify what action is to be taken and who is responsible for this. There are regular meetings to oversee progress. Sheppard Close has its own service development plan. This was last reviewed in November 2005, and is due to be evaluated again shortly. Targets include issues relating to the maintaining of service quality, staff training, and future improvements to the premises. The same staff member is also responsible for overseeing health and safety arrangements. CARE has a wide range of standard policies and manuals covering all aspects of this topic. The organisation has also entered into a consultancy agreement with another company specialising in health and safety, which will advise on various aspects of practice. There are regular recorded checks on all elements of health and safety. The co-ordinator oversees this process, ensuring that each area carries these out. This includes the required checks and instructions relating to fire safety. At Sheppard Close (1) DS0000028293.V305002.R01.S.doc Version 5.2 Page 25 Sheppard Close, current records are kept in the house, and then returned for central storage 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. 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. It was observed during the inspection that some fire restricting doors were held open with wedges. This was done to allow ease of access between different areas, and also to alleviate the effects of uncomfortable heating levels in some rooms. This practice is unsafe, because it means that fire can spread more rapidly if it occurs in the relevant areas. If fire restricting doors are to be kept open in normal use, they need to be fitted with a suitable device that will automatically ensure that they close if the alarms sound. Fire safety practices in the home include service users and staff. 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. However, there was no evidence at this inspection visit of an overall fire risk assessment for the premises. This is required, to address in suitable detail issues such as the particular hazards that may be present in the premises, and the measures that are in place to minimise any danger from these. This issue is of particular importance in light of changes to the system of fire safety regulation as it relates to care homes. Sheppard Close (1) DS0000028293.V305002.R01.S.doc Version 5.2 Page 26 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 3 35 4 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 3 X 3 X X 2 X Sheppard Close (1) DS0000028293.V305002.R01.S.doc Version 5.2 Page 27 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 YA42 Regulation 23-4c(i) Requirement Fire restricting doors must not be held open in a way that will prevent them operating effectively in the event of an emergency. The fire risk assessment must be reviewed. (Timescale of 21/11/05 not met) COMMENT: An overall risk assessment for the premises could not be located at this inspection. Timescale for action 06/09/06 2 YA42 23-4 30/09/06 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 YA9 Good Practice Recommendations Records relating to risk management decisions should make clear who has been involved in devising the agreed approach. Sheppard Close (1) DS0000028293.V305002.R01.S.doc Version 5.2 Page 28 2 YA24 Arrangements for heating should be reviewed, to try and ensure that comfortable levels are maintained in all parts of the home. Sheppard Close (1) DS0000028293.V305002.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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