Inspection on 25/07/07 for 10 - 11 Rowan Close

This inspection was carried out on 25th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

10 - 11 Rowan Close 20/04/06

10 - 11 Rowan Close 18/10/05

10 - 11 Rowan Close 14/12/04

10 - 11 Rowan Close 28/06/04

10 - 11 Rowan Close 01/03/04

10 - 11 Rowan Close 28/04/03

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

CARE HOME ADULTS 18-65 10 - 11 Rowan Close Pilands Wood Bursledon Southampton Hampshire SO31 8LF Lead Inspector Neil Kingman Unannounced Inspection 25 July 2007 13:40 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 10 - 11 Rowan Close DS0000012378.V341410.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. 10 - 11 Rowan Close DS0000012378.V341410.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 10 - 11 Rowan Close Address Pilands Wood Bursledon Southampton Hampshire SO31 8LF 023 8040 7870 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) www.macintyrecharity.org MacIntyre Care Mr Matthew Reeves-Smith Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 10 - 11 Rowan Close DS0000012378.V341410.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20 April 2006 Brief Description of the Service: 10-11 Rowan Close is a registered home providing care support and accommodation for up to six adults with learning disabilities. The home is managed by Mr Matthew Reeves-Smith on behalf of the providers Macintyre Care a national charity. Comprising two adjoining purpose built bungalows that mirror each other in size and layout, the home is accessible to wheelchair users and has been adapted to provide low kitchen surfaces, lowered light switches, specialist baths, moving and handling equipment and wide doorways. A sensory and herb garden has being created to one side of the property, with a patio and lawned area on the other. The home is located in a residential cul-de-sac on the Pilands Wood estate at Bursledon, and is within 100 metres of local shops, a community centre and a church. The home has its own unmarked minibus to provide transport for the people who use the service. Information about the home is made available to people who may wish to use the service by providing a copy of the home’s service user’s guide, statement of purpose and brochure. A copy of the last inspection report is available in the office. Although requested from the manager on several occasions the home’s fees have not been given to the Commission. Further information about the organisation can be found at www.macintyrecharity.org 10 - 11 Rowan Close DS0000012378.V341410.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the results of an evaluation of the quality of the service provided by 10 –11 Rowan Close and brings together accumulated evidence of activity in the home since the last key inspection on 20 April 2006, at which there were five requirements identified as needing to be addressed. On 25 September 2006 a random inspection of the home was carried out to follow up on those requirements. It was noted that three requirements had been met and two remained outstanding. A further three new requirements were identified. Part of the process has been to consult with people who use the service; including telephone discussions with three visiting relatives and an appointed advocate. There were no responses to a variety of survey comment cards sent to the home for distribution. Included in the inspection was an unannounced site visit to the home by an inspector on 25 July 2007. The registered manager Mr Reeves-Smith was available on the day. At the visit we had an opportunity to tour the building, speak with staff on duty and meet all six people who use the service. We also looked at a selection of records. Well before the site visit an Annual Quality Assurance Assessment form (referred to as the ‘assessment’ during the report) was forwarded to the home with sufficient time for its completion and return. However, the document was not returned without several reminders and in the event, it arrived at the Commission just two days before the site visit. What the service does well: This inspection at 10 – 11 Rowan Close has judged it to be an improving service with substantial strengths. The service is particularly good at: • • • • Supporting people with severe learning and physical disabilities to live a worthwhile and meaningful life. Planning care and support in an individualised, person centred way. Achieving positive outcomes for people by ensuring that the facilities, staffing and specialist services are provided. Being committed to improving experiences for people with the use of innovative technical aids and equipment. Quotes from visiting relatives during telephone discussions illustrate the home’s strengths: “The home provides individualised care.” 10 - 11 Rowan Close DS0000012378.V341410.R01.S.doc Version 5.2 Page 6 “I’m impressed with the staff and how they treat the resident with dignity and respect. They are careful in choosing his clothes.” “They are always doing something to improve the home.” “I can’t speak too highly about them – they are wonderful.” “The care is second to none. The manager, deputy and staff – brilliant.” 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. 10 - 11 Rowan Close DS0000012378.V341410.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 10 - 11 Rowan Close DS0000012378.V341410.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 – People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager ensures that the care support needs of the people who use the service will be met by undertaking a proper assessment prior to them moving into the home. EVIDENCE: Pre-admission assessment 10–11 Rowan Close provides long-term care and support for up to six adults with learning disabilities. At the last inspection this standard was judged to have been met. The manager confirmed that there had been no new admissions to the home since October 1999. It is therefore the case that the home has not had to implement its pre-admission assessment process for nearly eight years. However, it was noted that each person who uses the service has a needs assessment on his or her file. The manager showed a good understanding of the importance of a preadmission assessment in the process of choosing the right home, which includes contact with care managers and introductory visits by the prospective resident to establish compatibility with existing residents, and to judge whether the home would be suitable. 10 - 11 Rowan Close DS0000012378.V341410.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): 6, 7 and 9 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides care and support for people with physical and intellectual impairment and limited communication skills. Decisions about their lives are determined by assessment, recorded in individual personal plans, and are made within a risk assessment framework. EVIDENCE: Personal plans – The home operates a key worker system where key support workers known as ‘link workers’ have additional responsibilities for identified residents. Each person who uses the service has a personal plan, which reflects their individual needs, wants and goals. Information in personal plans is very person centred. We looked at a sample of three plans. The intention was to look at the outcomes for people in general by assessing all areas of care and support for those sampled. 10 - 11 Rowan Close DS0000012378.V341410.R01.S.doc Version 5.2 Page 10 All those who use the service have profound learning and physical disibilities, and most have significant communication difficulties. Their personal plans are set out in a way that ensures staff are made aware of all aspects of their daily lives including: how they are able to communuicate, what they like and dislike, where they like to go and what they like to do, what support they need and any other essential information. The plans have substantial strengths in areas such as the identification of preferences, needs and how people prefer to be treated. One part of the plans can be used to describe their importance in the everyday running of the home, i.e., “What I would like from everyday life.” A communication dictionary is included and pictorial images are used where appropriate All interested parties are invited to personal plan reviews included the people themselves, parents, link workers and care management. All staff spoken with are link workers. They confirmed their involvement in the updating of information on personal plans and felt that plans are working documents that are very person centred and used on a daily basis. Visiting relatives spoken with in telephone discussions confirmed that they were involved in care plan reviews and one said that the last review they attended lasted about two hours and the resident was very much involved in the process. Decision making The very complex needs of those who use the service mean that they need, and receive support to help them make decisions in their lives. Information in personal plans and discussions with staff on duty provided evidence of the extent to which staff go to make residents’ lives varied and worthwhile. The information about how best to support and communicate with people is a good example. We had an opportunity to spend time with the residents during the site visit. Some were noted to be very well kempt and relaxed in the familiar surroundings of their rooms, while others clearly enjoyed the one-to one attention of the staff in the sensory room. It was understood in discussions with the manager that all people who use the service have a family member to represent them. In addition, there is an appointed advocate allocated to the home. The manager said the advocate maintains regular contact with people who use the service and makes a great deal of effort to ensure that their rights as individuals are protected. Feedback from the advocate was very positive. Staff were viewed as well trained, and open and friendly at all times. Care and support for people was 10 - 11 Rowan Close DS0000012378.V341410.R01.S.doc Version 5.2 Page 11 considered very person centred. While the home always responds to suggestions and ideas positively it was felt they could be more proactive when considering the input from the advocate. It was reported that the advocate always initiates contact; perhaps because staff are so wrapped up with everyday life, advocacy may be an afterthought. We looked at the system in place to safeguard residents’ monies and found it to be satisfactory. In a dip-sample of records entries were accurately recorded and supported with receipts. There was evidence of regular monitoring to ensure accuracy. Risk taking – At the last inspection a requirement was made for the home to undertake risk assessments for any area of risk to service users and staff. During this site visit we noted specific risk assessments on residents’ personal plans, with clear guidance for staff on how risks are to be managed. In discussions with the manager and staff about examples of challenging behaviour it was clear that the home has strategies for managing situations, which keep incidents to a minimum. Provider’s Annual Quality Assurance Assessment The assessment identified what the service does well in this area: • • • • We support our house advocate in all that they do and always listen. All service users have a Person Centred Plan (PCP) in place. All service users have new bedrooms designed to reflect their personalities and needs. Employed a Community Activity C0-ordinator. 10 - 11 Rowan Close DS0000012378.V341410.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, 14, 15, 16 and 17 - People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are encouraged and supported to make choices about their lifestyle and develop skills. A range of activities meets individual’s likes, dislikes and expectations. People are supported to maintain regular contact with the local community and routines help to promote their independence. They are offered meals they enjoy, which are varied and healthy. EVIDENCE: Education and occupation The manager said that while people who use the service have varying levels of ability none has the capacity to develop employment skills or to take up opportunities for paid, supported or volunteer jobs. 10 - 11 Rowan Close DS0000012378.V341410.R01.S.doc Version 5.2 Page 13 It was understood in discussions with the manager and staff that prior to May 2006 there had been opportunities for people to develop life long learning through day service placements; indeed copies of life long learning achievement certificates were included in their personal files. However, the placements ceased to be available to all but one of the more able residents who regularly attends a day service in nearby Bishopstoke. Only in the last six months has there been funding available to introduce an activities co-ordinator to facilitate one-to-one activities for people throughout the week. According to the manager it is hoped that day service placements can soon be made available again to all those living in the home. Leisure, community links, social inclusion and relationshipsThere was evidence during the inspection that the home promotes the individual’s right to live a meaningful life, both in the home and in the community, examples being one resident who has been given access to a hydro pool and another who is due to take part in a sponsored walk with others in the local community who do not have their disability. Personal plans give information about leisure choices and preferences. They enjoy going out from the home when the weather is fine, and making use of the new sensory facilities the home now provides. These facilities are of particular benefit to those with sight and hearing impairment. We had an opportunity during the site visit to speak with the activities coordinator who confirmed that he supports people to do whatever they want either one-to-one or as a group. Popular activities include skating, cinema club and trips out, including boat trips. The home has a specially adapted people carrier to enable people with physical disabilities to make the most of outside excursions. Staff treat residents as individuals and support them variously to enjoy music and develop their various skills with art and crafts. Examples of residents’ work can be seen on display around the home. People maintain contact with their families to varying degrees and family and friends are welcome at anytime. Visitors can meet with people in their rooms or any of the communal areas. There are quiet facilities available for private meetings and consultations. It was clear from telephone conversations with visiting relatives that the home identifies what the residents like and dislike and then makes an effort to support them to do whatever they wish. It was confirmed that one individual is supported to attend the local church. Another relative made special mention of the way a resident’s room had been decorated to reflect their particular interest in music. In addition, they are given an opportunity to take a yearly holiday away from the home. 10 - 11 Rowan Close DS0000012378.V341410.R01.S.doc Version 5.2 Page 14 Daily routines Bedrooms were seen to be very well personalised and reflected residents’ different interests, personalities and preferences. A good deal of thought has gone into decorating each person’s room in a way that reflects their individuality. Staff respect peoples’ privacy and were seen to knock before entering their rooms. Communication is very good as we observed from interactions between staff and residents during the afternoon. It was clear that the residents hold staff in high regard. Only one person has the physical and cognitive ability to perform household tasks and is encouraged to do so. All areas of the home are ‘wheelchair friendly’ and are accessible to the people who live their, including the gardens, which have been developed to provide a sensory area, the benefits of which can be better seen at night when the area is lit up. Meals – The manager explained that due to the assessed needs of the residents their food has to be liquidised. However, he stressed the importance of ensuring the various ingredients of the meals being liquidised separately to preserve the different tastes. The four-week rotational menu shows food to be varied and appealing. Hot and cold drinks are available throughout the day. Provider’s Annual Quality Assurance Assessment The assessment identified what the service does well in this area: • • • We have employed a Community Activity Co-ordinator to support all service users with chosen activities. We buy in Music and Movement Class from Internet UK. We are constantly changing the environment to better suit the needs of our service users. 10 - 11 Rowan Close DS0000012378.V341410.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 and 20 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Personal support – At the time of the inspection there were six people resident at Rowan Close and all but one require support in all aspects of their daily lives. Peoples’ plans clearly record individuals’ personal and healthcare needs and detail how they prefer their support to be delivered. Staff use a person centred approach to deliver care and support and meet people’s changing needs, e.g., several with severe mobility difficulties have specially adjustable beds, and need individual approaches to managing their mobility. The home has been able to meet peoples’ specialist needs with two hoists and electrically adjustable baths to help staff to transfer them safely. In discussions with individual staff members it was clear that they have a good 10 - 11 Rowan Close DS0000012378.V341410.R01.S.doc Version 5.2 Page 16 understanding of residents’ needs and felt that while the home is very proactive in many areas there would be a benefit for both residents and staff with the fitting of ceiling hoists in the bathrooms. However, they recognise the cost implications of introducing such equipment. The home uses sensory equipment to provide a relaxing and stimulating experience for people with complex needs. Healthcare – Personal plans show that peoples’ health care needs are regularly addressed. They receive checks from the GP, dentist, optician and specialist health care professionals. All health care needs are identified in their personal plans. The manager explained that people have access to a particular GP at the local Blackthorn surgery who has a good understanding of their individual healthcare needs and is able to provide a co-ordinated approach. The manager confirmed that the home enjoys a good liaison with all other healthcare professionals. All visits to health clinics are planned between the resident and their key worker. There is a mix of male and female staff (although mainly female) to enable appropriate gender matches for intimate personal care where required. Medication We looked at the home’s arrangements for residents’ medication with the manager. Records showed that medication is administered by staff who have been trained in medicines management and deemed competent by the manager. At the time of the site visit residents’ medication was securely held, and records relating to its safekeeping and administration were found to be in good order. It was noted that individual PRN (as required medicines) protocols were in place. The manager said they had been developed since the last inspection. Peoples’ assessed needs are such that staff administer all of their medication for them. Provider’s Annual Quality Assurance Assessment The assessment identified what the service does well in this area: • • Our basic care is excellent; service users always look presentable and are bathed daily. We ensure regular health appointments; referrals are completed to outside agencies whenever needed. 10 - 11 Rowan Close DS0000012378.V341410.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 and 23 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, and are protected from abuse. EVIDENCE: Complaints At the last inspection this standard was judged to have been met. The home has a formal complaints policy and procedure, which is also in pictorial format. Three care support workers spoken with were clear about the procedure and showed a good understanding of how; through non-verbal signs they could tell if certain people were unhappy. They explained that with such complex needs residents rely almost totally on staff from one day to another, therefore, they had produced a very clear and concise complaints procedure, written in simple terms and prominently displayed on the wall. This is to ensure that any concern, however small, is picked up by staff, reported and resolved. The manager stated that there had been no formal complaints since the last inspection. All three relatives spoken with in telephone discussions knew how to make a complaint if they needed to. However, they all made the point that they were totally happy with the service. 10 - 11 Rowan Close DS0000012378.V341410.R01.S.doc Version 5.2 Page 18 Safeguarding adults The home has a safeguarding adults policy and procedure in place, and staff receive specific training in the subject. Staff spoken with confirmed that they had received training in safeguarding adults and were very clear about the importance of reporting issues of concern without delay. Provider’s Annual Quality Assurance Assessment The assessment identified what the service does well in this area: • • • We keep a complaints book; all complaints are actioned ASAP. MacIntyre employ a person with learning disabilities to travel from service to service to listen to service users. MacIntyre employ a Communication Mentor. 10 - 11 Rowan Close DS0000012378.V341410.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 and 30 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home’s premises are suitable for its stated purpose. They are comfortable, safe and well maintained. On the day of the site visit the home was clean, hygienic and free from unpleasant odours. EVIDENCE: Premises The home provides a physical environment that is appropriate to the specific needs of the people who live there. As described earlier in the report specialist aids and equipment are provided to meet peoples’ needs. At the site visit we toured the building with the manager and noted the home is a very pleasant and safe place to live, being a single storey purpose built building with all bedrooms located at ground level. 10 - 11 Rowan Close DS0000012378.V341410.R01.S.doc Version 5.2 Page 20 The bedrooms and communal rooms meet the National Minimum Standards or are larger. All rooms are for single occupancy and while they do not have ensuite facilities they have washbasins. All residents require support for all their personal care needs and specially equipped bathrooms and toilets are located within easy reach of bedrooms and communal areas. People are encouraged to personalise their bedrooms and all the homes fixtures and fittings meet the needs of the individuals and can be changed if their needs change. All bedrooms have been newly decorated and staff have had a major input in personalising rooms to reflect individual personalities. The home provides a wide range of communal shared space. There is a wellfurnished comfortable lounge, a large kitchen/diner, a sensory room with a wide range of sensory equipment for touch, sight and sound, and an arts and crafts room. The home has plenty of lockable storage space and a staff sleep-in room. It was noted that since the last inspection the home has met all outstanding environmental requirements. The kitchen has been fully refurbished and stained and worn floor surfaces replaced. The three visiting relatives spoken with made very complimentary remarks about the environment and the efforts of staff to make rooms very person centred for the residents. Cleanliness It was noted during the site visit that all areas of the home were very clean, hygienic and free from unpleasant odours. There are two spacious laundry rooms fitted with commercial grade machines, enabling articles to be washed at appropriate temperatures. There is a separate mechanical sluice for effective management of soiled articles due to incontinence. The home’s assessment indicates that all policies and procedures are in place for infection control. Provider’s Annual Quality Assurance Assessment The assessment identified what the service does well in this area: • • • • • We We We We We evolve the environment to better suit the needs of our service users. have a sensory garden. have a sensory room. have personalised bedrooms. have an arts and crafts room. 10 - 11 Rowan Close DS0000012378.V341410.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home are trained, skilled and are deployed in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: Staff recruitment The manager confirmed that two new care support workers had been recruited since this standard was last assessed. As at previous inspections it was confirmed that records relating to the recruitment of new staff are held centrally at the organisation’s head office. However, evidence of the required, written references and police and Protection of Vulnerable Adults (POVA) checks were available to demonstrate robust vetting procedures. 10 - 11 Rowan Close DS0000012378.V341410.R01.S.doc Version 5.2 Page 22 Staff training, development and competencies The home’s assessment indicated that there is a staff development programme that meets National Minimum Standards for the service. During the site visit there was an opportunity to look at the staff training plan and a sample of individual training profiles. A prominently displayed training calendar shows at a glance the dates scheduled for refresher training. Records demonstrate that the full range of mandatory training is provided together with additional service specific training such as: • • • • • • Epilepsy Challenging behaviour Communication Risk assessment Medicines management Infection control The manager described and produced evidence of the induction programme care support workers undertake when joining the home. The current programme follows the Common Induction Standards recommended by ‘Skills for Care’ and follows the Learning Disabilities Award Framework (LDAF). The manager confirmed and records showed that five of the fourteen care support workers have achieved the National Vocational Qualifications (NVQ) at level 2 or above and four are currently working towards the qualification. The manager has recognised the low percentage of NVQ trained staff in the home’s assessment and has included further training in plans for improvement in the next twelve months. Care support workers spoken with said that the home provides a good staff training package, which equips them well for the work they do. This was echoed in discussions with the advocate who felt that staff showed dedication and were very person centred. 10 - 11 Rowan Close DS0000012378.V341410.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a competent manager who is currently undertaking the relevant management training. EVIDENCE: Management – The registered manager Mr Matthew Reeves-Smith has been in post for about two years and is currently undertaking training for NVQ level 4 in care and the Registered Managers Award (RMA). Once the qualifications have been achieved this standard will be fully met. He states that he keeps up to date with regular mandatory and service specific training, and adopts a ‘hands-on’ approach to the running of the home, working alongside care support workers where appropriate. 10 - 11 Rowan Close DS0000012378.V341410.R01.S.doc Version 5.2 Page 24 All staff spoken with regarded the home as being well run, with regular staff meetings and formal supervision. They confirmed that the morale of staff was good and the manager was approachable and supportive. An area for management improvement can be found in the approach to administrative tasks. The Annual Quality Assurance Assessment was forwarded to the home with sufficient time for its completion and return. Following discussions with the manager survey comment cards were sent to the home for distribution to stakeholders and all interested parties. However, the survey forms were not distributed and the assessment was returned just two days before the site visit, and only then after several reminders. Quality assurance – The MacIntyre organisation’s website describes their own quality monitoring system (Investing in Care - IIC), as being an Investors in Care audit, and Performance Measures using six promises, which are part of MacIntyres’ core values. The manager gave examples and we saw some records of the home’s approach to quality assurance, which includes: • • • • • Yearly care reviews involving the social services care manager, the key worker, the resident and a relative. Regular statutory visits by the proprietor to monitor the conduct of the home. Regular staff meetings and formal supervision sessions. Written satisfaction surveys sent to families and interested parties. MacIntyre employ a person with learning disabilities to travel from service to service to meet with and listen to people who use the service. A published report summarises the findings and any recommendations that have arisen. Health and safety The home’s assessment confirmed that policies and procedures were in place to ensure safe working practices in the home. A sample of records was viewed including health and safety risk assessments, fire alarm tests and drills, public liability insurance, and gas and electrical certificates, all of which were in good order. Staff training records showed, and staff confirmed that statutory training is scheduled and updated in manual handling, first aid, fire training, infection control and food hygiene. 10 - 11 Rowan Close DS0000012378.V341410.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 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 2 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 4 14 4 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 10 - 11 Rowan Close DS0000012378.V341410.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 10 - 11 Rowan Close DS0000012378.V341410.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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