Inspection on 09/10/07 for 1 Upfield

This inspection was carried out on 9th 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 Upfield 19/12/06

1 Upfield 19/01/06

1 Upfield 21/11/05

1 Upfield 26/01/05

1 Upfield 27/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Upfield (1) 1 Upfield Horley Surrey RH6 7JY Lead Inspector Joseph Croft Unannounced Inspection 9th October 2007 10:30 Upfield (1) DS0000013441.V348755.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 Upfield (1) DS0000013441.V348755.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. Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Upfield (1) Address 1 Upfield Horley Surrey RH6 7JY 01293 782396 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) UPFIELD@HOTMAIL.CO.UK Gresham Care To be confirmed Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be 18 -45 YEARS 7th December 2006 Date of last inspection Brief Description of the Service: Upfield is a registered care home for six people with a learning disability, and is located in Horley, Surrey. The property is detached and accommodation is on two floors accessed by stairs. The home has six single bedrooms, a lounge, kitchen/dining area, bathrooms, toilets, showers and office. Public amenities are easily accessible and the home is within walking distance of the local town centre with banks, post office, restaurants, pubs, and various shops. The home has a large garden that is well maintained and secure. Private parking is available. The weekly fees range from £1300 to £2200. Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 9th October 2007 using the ‘Inspecting for Better Lives’ (IBL) process. This visit was undertaken by Regulation Inspector Mr Joe Croft and took five hours, commencing at 10:30 and concluding at 15:30. The acting manager informed the Inspector that people living at the home like to be referred to as ‘clients’, therefore this term is used throughout this report. The inspection process included a tour of the premises and sampling of clients’ care plans and risk assessments. Other documents sampled included the staff duty rota, menu, policies and procedures and records of medication. The Inspector had discussions with one client and members of staff on duty. Due to the profound learning and communication difficulties, it was not possible to ascertain the views and opinions of all clients living at the home. Clients were observed to be appropriately cared for, with staff attending to and supporting individuals as and when required. Staff spoken to were complimentary about the acting manager of the home. The Annual Quality Assurance Assessment (AQAA) completed by the home and three surveys returned to the Commission For Social Care Inspection have been used as a source of evidence in this report. The inspector would like to thank the members of staff and residents for their cooperation during this visit. What the service does well: People who use the service have care plans and risk assessments in place, which ensures their needs are met. Clients are supported by staff to lead active lives. Clients are encouraged by staff to participate in a range of activities both within the home and the local community. A healthy and balanced diet is provided. People who use the service are protected by the home’s storage, administration and recording of medication procedures. Physical and health care are offered in such a way as to promote clients’ independence. Clients and their relatives have access to a satisfactory complaints system that enables them to raise concerns. Staff having knowledge, training and an understanding of adult protection issues protect the clients. The home has recently had an extension that accommodates a good size kitchen, with new fittings and fixtures, dining area and a separate laundry room. The home provides good communal and individual living space making it a safe and comfortable place to live. Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 6 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. Upfield (1) DS0000013441.V348755.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 Upfield (1) DS0000013441.V348755.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): Standard 2 was assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Assessment documentation is in place to ensure the individual needs of clients can be met. EVIDENCE: The home follows the organisation’s Policy and Procedure for Referral and Admissions. This informs of the procedures to be followed, and that prospective clients are to be encouraged to visit the home to meet with the other clients and to discuss the bedroom they would occupy. The last client admitted to the home was in 2006. The pre-admission assessment of this person was viewed as part of the case tracking process. This included information in regard to personal, physical and health care, communication, emotional support and activities of daily living. The acting manager informed the Inspector that assessments are always requested from care managers, and that a visit to the prospective resident is undertaken by the organisation’s general manager to conduct an assessment for the home. Evidence of this was viewed during the site visit. Unfortunately, due to their profound learning and communication difficulties, it was not possible to ascertain the views of residents in regard to their admission to the home. Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 9 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): Standards 6, 7 and 9 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have care plans and risk assessments in place, which ensures their needs are met, and they are supported by staff to lead active lives. EVIDENCE: Clients living at the home are from different cultural backgrounds, and are cared for by a multi-cultural staff team. Staff informed the Inspector that clients have chosen not to follow their religion, however, the home provides meals from different cultural backgrounds on a weekly basis. One survey from a relative informed that the home always meets the cultural needs of clients. Two care plans were sampled as part of the case tracking process. These had been developed from the information provided in the pre-admission assessments. Care plans included information in regard to family history, likes and dislikes, physical, personal and health care, social skills, cultural, political Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 10 and religious needs and daily living skills. Aims and objectives are clearly recorded. Care plans had been signed by staff but not by clients. The acting manager informed the Inspector that not all clients are able to sign their care plans, but they are included in the reviewing process. A good practice recommendation has been made that the reason for clients not signing their care plans should be recorded. Statutory reviews of care plans had been conducted, and key workers had undertaken six monthly reviews. Clients, who are able to, have copies of their care plans in their bedrooms. One client had his care plan in his bedroom, and writes his own daily record sheets. Staff at the home monitor these on a weekly basis. The home has developed a book for each client entitled “What I Need”. This provides clear information to staff in regard to what is important to the client, their likes and dislikes, how they communicate and their behaviour. The deputy manager informed the Inspector these documents are written with the clients. Staff informed the Inspector that clients are provided with the opportunity to make decisions, but due to their low levels of understanding and communication needs, this can be difficult at times. Staff use the Widget symbols and Pictorial Exchange Communication system (PECs) to help clients with this process. Evidence of this was seen throughout the home during the site visit. One client was able to communicate with the inspector. He stated that he does make decisions; recently he had chosen the colours for the redecoration of his bedroom that is due to take place. This client also informed the Inspector that he and the other clients choose the weekly menus. Surveys received from clients informed that they can choose to do what they want during the day and evening. Care plans sampled included risk assessments pertaining to the individual. These include risks in regard to all daily living activities and are reviewed twice a year. It was noted that each member of staff had signed to signify they had read and understood the risk assessments. Risk assessments viewed were detailed, however, a good practice recommendation has been made that the risk assessments should include instructions on the action to be taken when a client becomes exposed to an identified risk. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 11 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): Standards 12, 13, 15, 16 and 17 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are encouraged by staff to participate in a range of activities both within the home and the local community. A healthy and balanced diet is provided for clients. EVIDENCE: Clients living at the home attend day centres, and some are in salaried employment that include paper rounds and working in local stores. This actively promotes community links and social inclusion. Information provided in the AQAA informed that clients have a weekly activity list, and take part in a variety of activities that include visiting local parks, pubs, shopping and using the local leisure facilities. This was confirmed during discussions with staff who also stated they take clients to the local restaurants and annual holidays to places of their choosing. The home has its own transport that enables clients to access the community. During discussions staff informed the Inspector that clients are provided with activities of their choice. Evidence of activities was recorded in individual care files. Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 12 The acting manager informed the Inspector that no current client is involved in a relationship, but advice and support would be provided as and when appropriate. Staff at the home work with clients to try and enable them to understand sexual issues. Staff and one client informed the Inspector that there are no restrictions on visitors to the home. Clients are able to use the home’s cordless telephone to make and receive telephone calls, and all receive their own mail. Staff stated that support is provided to those who need it as and when required. Clients living at the home have regular contact with their families, and have the opportunity of going to their relatives’ homes for weekends and holidays. Staff stated they respect clients’ privacy and dignity through knocking on bedroom doors, calling clients by their preferred names and providing personal care in the privacy of their bedrooms. Evidence of these practices was observed during this site visit. Clients are provided with keys to their bedrooms. The home follows the organisation’s Policies and Procedures in regard to Privacy and Dignity that was last reviewed on the 18th August 2007. Staff working at the home attend the Learning Disability Award Framework (LDAF) training that includes Privacy and Dignity awareness. The AQAA informs that clients are encouraged to take part in general household chores at the level and pace they are able to. During discussions staff and one client informed the Inspector that all the clients choose the weekly menu every Sunday. The home uses photographs of meals that enable clients to make these choices. The menu is then displayed in the dining room. The deputy manager informed the Inspector that the shopping is undertaken on a weekly basis, and clients are encouraged to help. Records of menus were viewed during the site visit. Menus included fresh meat, fish, pasta, salad, fresh vegetables and fresh fruit. A recommendation made at the previous inspection was that a Dietician should view the menus. This was undertaken in April 2007, and the home had followed the recommendations that were made. Staff and clients cook the meals at the home. Evidence was viewed in training files that staff had received training in regard to food handling and hygiene. It was noted that two clients had also attended this training. The acting manager informed the Inspector that currently no client has any special dietary requirements. Records of all meals taken by clients are maintained by the home. One client informed the Inspector that the food was very good, and “we always choose every Sunday”. Menus viewed also included a weekly national meal for residents. Information provided in the AQAA informs that staff help clients to prepare and cook meals from African and Caribbean ethnicity. Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 13 Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 14 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): Standards 18, 19 and 20 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are protected by the home’s storage, administration and recording of medication procedures. Physical and health care are offered in such a way as to promote clients’ independence. EVIDENCE: Discussions with staff and one client, and the sampling of the records, provided evidence that each client receives the agreed personal care and support as recorded. Staff informed the Inspector that clients are able to attend to their personal needs, but advice is offered as and when appropriate. Clients are supported to choose the time they go to bed and get up in the morning, the clothes they wish to wear and their hairstyles. Care plans sampled evidenced clients are registered with the local GP practice, Dentist, Optician, and have access to all National Health Services. Records of appointments and annual check ups at the well person clinic are maintained. The home uses the Medical Administration Record sheets (MARs) provided by the local pharmacy for the recording of medicines. Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 15 The home maintains records of medicines received and returned to the Pharmacist. Medicines are appropriately stored in a locked metal medicine cabinet. The MAR records for clients who were part of the case tracking process were accurately maintained. Staff informed the Inspector that no client is self-medicating or taking a Controlled Drug. Evidence of training in regard to staff dispensing medication was viewed on the training records sampled during this site visit. Staff at the home follow the organisation’s Policies and Procedures in regard to dispensing medication. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 16 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): Standards 22 and 23 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a satisfactory complaints system that enables clients and their families to raise concerns. Staff having knowledge, training and an understanding of adult protection issues protect the clients. EVIDENCE: The Commission For Social Care Inspection has not received any concerns, complaints or allegations in regard to the care home. The home follows the organisation’s Complaints Policies and Procedures that was reviewed in August 2007. This details the procedures to be followed with timescales for responding to complainants and the Commission For Social Care Inspection contact details. A member of staff at the home had developed this document using the widget symbols and key words, which enables the clients to understand the information they have been provided. During discussions, one client informed the Inspector that he would talk to members of staff if he felt unhappy or sad, or wanted to make a complaint. Surveys received from clients informed that they know how and who to make a complaint to. The home had received one complaint since the previous inspection. This was referred to in a survey received from a relative. This had been satisfactory concluded. Evidence of the action taken and response to the complainant was viewed during this site visit. Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 17 The home follows the organisation’s Protection of Vulnerable Adults Policy and Procedure that was reviewed in August 2007. A copy of the recent Surrey Multi-Agency Safeguarding Procedures is available in the office for staff to read. During discussions staff were able to demonstrate an understanding of Safeguarding Adults issues. Staff stated they would report all concerns to the manager, the organisation and the Commission For Social Care Inspection as appropriate. Staff stated they would not hesitate in reporting bad practice. The sampling of four staff training files provided evidence that training in regard to Safeguarding Adults took place on the 30th January 2007. The manager informed the Inspector that all staff have attended this training. Evidence was viewed that the acting manager had attended Safeguarding training on the 21st September 2006. The acting manager informed the Inspector that he is making an application for a place on the Surrey multiAgency training in regard to Safeguarding Adults. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). The acting manager informed the Inspector that clients and/or their relatives are responsible for their finances; however, the home does hold a small amount of money for clients. Two members of staff check the records and monies held twice a day. Records were viewed, and the money held balanced with the records maintained by the home. Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are provided with good communal and individual living space making it a safe and comfortable place to live. EVIDENCE: A tour of the premises was undertaken. The property is detached and accommodation is on two floors accessed by stairs. The home has six single bedrooms, a lounge, kitchen/dining area, bathrooms, toilets, showers and office. The lounge and hallway had been redecorated and new carpets had been laid. The home recently added an extension that accommodates a good size kitchen, with new fittings and fixtures, dining area and a separate laundry room. The laundry has washing machines with a sluice facility. Kitchen cupboards were clearly marked using widget symbols that informed clients where to find utensils and other kitchen equipment. Daily records of fridge/freezer and cooking temperatures were maintained. Bedrooms were appropriately furnished and clients had their personal belongings. One client informed the Inspector that he liked his bedroom, and that he has chosen the new colours for when it is next decorated. Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 19 It was observed that there were alarms on two bedroom doors. The acting manager informed the Inspector that risk assessments were in place for the use of these, however, the Inspector did not view them during this site visit. Staff informed the Inspector that clients clean their bedrooms and the communal areas of the home with staff support. Communal toilets and bathrooms had liquid soap, however, not all had paper towels. This was discussed with the acting manager who informed that due to the complex understanding needs of some clients, it was not feasible to have paper towels, and therefore hand towels are used. As discussed with the acting manager, a requirement has been made that risk assessments in regard to the use of hand towels in communal areas must be undertaken. Parts of the home had recently been redecorated, and the acting manager stated that the organisation has a development plan for the redecoration of bedrooms that is ongoing. On the day of the site visit the home was clean, tidy and free from offensive odours. Surveys received from clients informed that the home is always fresh and clean. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, 35 and 36 were assessed. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are satisfactory, ensuring staff have the qualities and training to meet the needs of the clients. People who use the service are protected by the organisation’s recruitment policy and procedures; however, staff recruitment files require further information. EVIDENCE: The staff team is made up of male and female staff. The duty rota viewed during the site visit provided evidence that there are five staff on duty during the early shift, and three staff during the late shift. One member of staff does a sleep in duty each night. Clients’ surveys inform that the staff treat them well and always listen and act on what they say. Information provided in the AQAA and during the site visit informs that 50 of the staff hold the minimum of NVQ level 2 and above. The home follows the organisation’s Recruitment Policies and Procedures. Three staff recruitment files were sampled. Each contained an application form, two written references, Criminal Records Bureau clearances and Protection Of Vulnerable Adult (POVA) first checks, photograph and proof of identification. It was noted that one application form did not provide a full Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 21 employment history, one did not have a record for a gap in employment, and one reference had not been obtained from the previous employer that involved working with vulnerable adults. The acting manager informed the Inspector that two reference requests had been sent to this employer, but they had failed to respond. Requirements have been made in regard to recruitment. After this site visit the acting manager contacted the Inspector and stated that he had contacted this person’s previous employer by telephone who has agreed to forward the reference. The acting manager stated that an audit of the recruitment files had been undertaken, and missing information has been addressed. Information provided in the AQAA informed that the organisation aim to recruit staff to reflect the ethnicity of clients living at the home. Staff at the home are provided with a copy of the General Social Care Council’s code of conduct and practice. The sampling of training records provided evidence that staff are receiving training appropriate to the work they perform, which includes Autistic Spectrum Disorder, LDAF (Learning Disability Award Framework) and Epilepsy. Evidence was viewed that staff receive Induction training. These records were signed and dated, which was a requirement made at the last inspection. The viewing of records and discussions with staff provided evidence that all staff are receiving regular formal one to one supervision and an annual appraisal. Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The arrangements for management and administration ensure the home is run in the best interests of clients, however, issues in regard to recruitment must be addressed to ensure the safety of clients. EVIDENCE: The acting manager informed the Inspector that he holds the NVQ level 4, and has six years experience of working in residential care of adults with a Learning Disability, during which he has managed three homes. Evidence was seen of the training the acting manager has undertaken to ensure he has the skills and knowledge to manage the home. The acting manager is currently undertaking the Registered Managers Award (RMA) and expects to complete this in May 2008. The acting manager informed the Inspector that an application for registration with the Commission For Social Care Inspection had been submitted, and is Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 23 waiting for an interview date. This was confirmed during a discussion with the Link Inspector for the home. During discussions, staff informed the Inspector that the acting manager has an open door policy, is approachable and there are good relations between the management and the staff team. The home follows the organisation’s policy on quality assurance and used questionnaires to obtain feedback about the home from service users, relatives and stakeholders. Evidence was viewed that a survey was carried out in March 2007; the findings were available at the home for information. The inspector noted a neighbour had completed a quality assurance questionnaire in March 2007 about the home that indicated satisfaction with the home, staff and service users. The general manager from the organisation undertakes monthly Regulation 26 visits, and reports of these are maintained at the home. The acting manager informed the Inspector that the home does not hold monthly client meetings as this raises the anxiety levels of clients. However, evidence was viewed that clients are kept informed of events at the home. Staff and one client informed the Inspector that all clients and staff informally discuss the week’s menu every Sunday. The sampling of training records provided evidence that staff are receiving all mandatory training as required. It was noted that staff require training in regard to Manual Handling, however, this had already been booked for the 24th October 2007. The requirement made at the last inspection in regard to Infection Control training had been complied with, and a further training has been organised for the 16th November 2007. Information provided in the AQAA informs that annual testing of Health and Safety equipment had been undertaken. The following were sampled during this site visit: Landlord Gas Safety, 24/09/07, Portable Appliance Testing (PAT), 25/06/07 and fire alarms and emergency lighting, 11/09/07. The acting manager informed the Inspector that the home had an inspection from the Surrey Fire and Rescue Team on the 26/09/07, and is waiting for the report. This inspection identified three issues which the home are addressing, one fire door requires a cold smoke seal, the fire risk assessments must be reviewed, and the risks in regard to keeping the front door locked to be reviewed. The person responsible for this informed the Inspector that a further meeting is to be held with the Surrey Fire Safety Officer on the 16th October 2007. Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 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 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 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 3 X Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 25 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 YA30 Regulation 13 (3) Requirement Timescale for action 09/11/07 2. YA34 19 (1) (b) 09/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA9 Good Practice Recommendations The reason for clients not signing their care plans should be recorded. Risk assessments should include instructions on the action to be taken when a client becomes exposed to an identified risk. Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House, 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Upfield (1) DS0000013441.V348755.R01.S.doc Version 5.2 Page 27 - 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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