Inspection on 31/01/07 for 12-13 Exbury Place

This inspection was carried out on 31st January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

12-13 Exbury Place 27/01/09

12-13 Exbury Place 21/02/06

12-13 Exbury Place 17/08/05

12-13 Exbury Place 21/02/05

12-13 Exbury Place 15/07/04

Similar services:

Aston Court Nursing Home

Breme

Ravenhurst

Westmead

Ashcroft Hollow Nursing Home

Bricklehampton Hall Nursing Home

Briar Hill House

Radbrook Nursing Home

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

CARE HOME ADULTS 18-65 Exbury Place, 12/13 12/13 Exbury Place St Peter The Great Worcester Worcestershire WR5 3TP Lead Inspector Christina Lavelle Unannounced Inspection 31st January 2007 1.40- Exbury Place, 12/13 DS0000018651.V321052.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 Exbury Place, 12/13 DS0000018651.V321052.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. Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Exbury Place, 12/13 Address 12/13 Exbury Place St Peter The Great Worcester Worcestershire WR5 3TP 01905 611147 01905 612958 andrew.deakin@scope.org.uk 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) SCOPE Mr Andrew Joseph Deakin Care Home 4 Category(ies) of Physical disability (4) registration, with number of places Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is for service users with physical disabilities but may also accommodate people who have associated learning disabilities. 21/02/06 Date of last inspection Brief Description of the Service: The service provider is SCOPE, which is a national organisation and registered charity providing a range of services for people with cerebral palsy and other physical disabilities. Exbury Place was first opened as a care home in 1993 and is part of a local community project called 1st Key Worcestershire. 1st keys office is at Unit 3, Lowesmoor Wharf, Lowesmoor, Worcester, WR1 2RS (tel no. 01905 611147) and the registered manager (Andrew Deakin) is based there. The vision statement of the 1st Key service is to empower service users to lead their lives in the way they choose and SCOPE’s man aim is that disabled people achieve equality. Exbury Place provides accommodation with personal care for four adults (men and women) who must be aged less than sixty-five. Service users must require care due to cerebral palsy, or a similar physical disability, and may also have an associated learning disability. Most service users have complex needs and so are very dependant on staff for all their care needs. The property is owned by a housing association and is leased to SCOPE. The home is a bungalow on a large modern housing estate, which is a couple of miles from Worcester city centre and close to Junction 7 of the M5 motorway. There are local shops and other amenities nearby and the home provides two suitably adapted vehicles to facilitate access in the wider community. The bungalow was especially adapted for its purpose and so all internal areas and the garden are accessible to wheelchair users. Service users have single bedrooms, none of which have en-suite facilities. There is a sitting room, kitchen/dining area, shower room and assisted bathroom for all to use. Also a utility room and staff sleep-in/office. The kitchen has low-level surfaces to make it easier for wheelchair users to help with food preparation and cooking, Information about the home is provided in a statement of purpose and service users’ guide that are available from the home and SCOPE office. The current fee for the service ranges from £52.000 up to £63.000 per year. Extra charges are made for such as hairdressing, personal telephone calls, shopping & travel, chiropody, newspapers & magazines. Funding for activities and holidays is as agreed between the service and individual service users’ funding authorities. Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a key inspection of Exbury Place. This means the inspector checked all the Standards that can have most effect on people who live in care homes. This visit was made on a Wednesday, without telling the home beforehand. The inspector spent time with service users and spoke to two of them alone in their bedrooms. It is difficult for some service users to say what they think of Exbury Place because of their disabilities, but they had all completed surveys showing their views of the home, with support from their keyworker. The team leader and a support worker were spoken with individually about service users and their care. They were also asked about how new staff are appointed and the training and support staff receive. Everyone was very open and helpful A relative of one service user was visiting the home today and discussed their views of the service with the inspector. Three relatives and two health or social care professionals had also sent in comment cards showing what they think about the home. All their feedback is referred to in this report. Some records kept by the home were checked and most of the bungalow seen. There is helpful information in a questionnaire the team leader had completed before this visit. All information received by the Commission about the home is also considered, such as notifications of events that had affected service users. What the service does well: There is good written information about Exbury Place to give to possible new service users. The manager would also meet them and they would be able to visit and try out the home to check it would be suitable before they moved in. Service users are well settled and say they are happy living at the home. One comments “It’s nice at Exbury Place”. It feels relaxed and friendly in the home. Service users have a written plan to help staff know their personal care needs and how to meet them. Plans include what each person likes and dislikes, and how and when they prefer to do things, such as getting up and what they eat. Service users receive some individual support from certain staff at the home, chosen to be their keyworker. They spend more time with them and help to review their plans and arrange their activities, trips out, shopping and health care checks. Service users are able to follow their own interests and take part in activities they like, when they are at home and out in the community. Keyworkers also support service users to keep in touch with their families. Some relatives say staff make them welcome and keep them informed about their care. They are all satisfied with the overall care provided by the home. Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 6 Staff support service users well with their personal care. They also make sure they stay in good health and have regular health care checks. One health or social care professional comments: “The SCOPE team communicates well with us and they provide very good care” and another “I believe that the service provided by Exbury Place has been excellent and have no complaints.” Exbury Place has given service users the opportunity to live in an ordinary, comfortable home and so be part of the community. The bungalow is adapted and equipped to meet their special needs and staff keep it safe and clean. There is a full and stable staff team. This is good as staff and service users know each other well and so service users receive more consistent support. The staff team work well together and are supported to do their job properly. SCOPE arrange for staff to have training to help them meet service users’ care needs better and keep them safe. New staff have a good introduction to the home and are checked to ensure they are suitable to work caring for people. 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. Exbury Place, 12/13 DS0000018651.V321052.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 Exbury Place, 12/13 DS0000018651.V321052.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): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. The home provides information to help prospective service users decide if they might like to live at Exbury Place and if the home could meet their needs. There are thorough assessment procedures in place to help to make sure that the home would suitably meet the needs of prospective service users. EVIDENCE: SCOPE provides appropriate information documents for the home, including a statement of purpose and a service users’ guide. There is also written guidance on the assessment of prospective service users’ care needs for when referrals are made, with a placement procedure flow chart and a care profile tool. Although there has not been any new service users at the home for years the team leader confirmed the process that would be followed by the home should a vacancy arise. This would include visiting a possible resident at their current home to assess their needs, after receiving a community care assessment from their funding authority. Introductory visits to the home would then be arranged e.g. for tea and overnight, followed by a trial stay. Review meetings are next held after a three month trial stay, involving relevant people so that a decision can be made about the placement continuing and fee & support levels agreed. Exbury Place, 12/13 DS0000018651.V321052.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. Service users receive good support from staff who help them to plan their care and minimise risks to their safety, whilst promoting their independence. Plans should also reflect their goals and if they have been achieved, with outcomes. Service users are able to make some decisions in their daily lives and routines. EVIDENCE: A sample of service users’ care records were looked at, one in detail. They include a pen picture, completed when the person had moved into the home, and their preferred daily routines. Staff also keep reports of significant events in service users’ lives, such as health care checks, family contact and activities participated in, so providing helpful information about their health and welfare. Each service user has a care plan that covers relevant areas of need, with a checklist of any action and support needed to meet their identified care needs. However the plans do not include much detail of their personal goals. It is Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 10 expected that service users’ aspirations and goals should form the basis of their plans and be “person centred”. Action specified to meet any goals should also be followed up in care reviews and plans show if they have been achieved and of the outcomes and any benefits (or not) to the individual service users. One plan seen had been drawn up and signed as agreed by the service user in 2005. There are dates recorded since when the plan was reviewed, although this indicates their needs have not changed. The last review was agreed last September and appropriately reviews are carried out by the home at least six monthly. Annual placement reviews are also arranged with service users’ funding authorities, attended by social workers and their families and anyone else service users wish to attend are invited. The team leader said the home is soon to introduce a format for keyworkers to review service users’ care and needs etc with them in a monthly discussion, which will be good. Service users each have a keyworker from the support staff team, who has some responsibility for making sure that their personal, social and health care needs are being met. Staff are clear about their role as a keyworker and one said he is able to offer his allocated service user more individual time and they have occasional days out together. He also has more to do with their life e.g. family contact and attending care reviews. One service user says she likes her keyworker and that she looks after her well and takes her shopping. Risk assessments have appropriately been carried out in relevant areas to help staff safeguard service users and to promote their independence. They include moving & handling, going out in their wheelchair, road skills, being left alone in the home and holding their own key. Service users are supported to make choices in their lives and one service user said “I make my own decisions”. Two others indicated they are usually able to make day-to-day decisions, but clearly this is restricted at times due to the level of their disabilities and dependence on staff support. Regarding equality & diversity SCOPE operate a national training programme for staff covering a range of topics, including disability awareness and anti-discriminatory practice. Exbury Place, 12/13 DS0000018651.V321052.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): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. Service users are supported to pursue individualised activities of their choice, and to mix within the community. This would be demonstrated more clearly if plans include more detail of their social needs and goals and how they are met. Staff support service users to maintain contact with their families. They also provide them with meals they like, whilst aiming to promote healthy eating. EVIDENCE: Service users’ plans show their interests and activities they have taken part in. Some attend day services and life skills courses at college. One person doesn’t have an activities plan as such, as apparently they no longer wish to follow set activities, preferring to go out locally or watch TV etc at home when they want. Plans do not however include much information about service users’ social & developmental needs and goals. They should also reflect an individual’s choice Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 12 not to take up opportunities to develop their skills or have more varied leisure activities. Care reviews and records should show if service users have enjoyed and/or benefited from activities and how staff continually encourage them to take up meaningful activities and seek other opportunities they could like. Only one service user is able to go out alone and often visits another SCOPE home or to Tescos shopping. Other than weekday placements, trips out have to be planned, as service users all need support. There is a driver/enabler for 1st Key services and a community enabler who works for Exbury Place one day a week, otherwise the staff team provide the support. The team leader said staff work flexibly to accommodate activities and she feels service users are normally able to go out and take part in activities when they wish, although this can be affected by staff availability. Two service users say that sometimes this can affect them doing what they want, but generally they accept this. In respect of daily routines staff say service users choose their own as far as is feasible, and one service user confirms they get up, go to bed etc. when they want. There is also a limit to how far service users could take responsibility for the day-to-day running of the household, due to their disabilities. Staff cook and carry out most tasks, but try to keep them involved as much as possible. There is an open and relaxed atmosphere in the home and a visiting relative clearly feels comfortable there and is made welcome. This relative said Exbury Place has been a godsend and overall was very positive about the service it provides. Service users have contact with their families if they wish, and can telephone them and/or their keyworker supports them with visits. Two other relatives confirm they are made welcome in the home, and are kept informed. Regarding food provision service users have their own housekeeping money for food and cleaning products etc. They choose to have a joint daily main meal and help staff with the shopping locally. Staff and service users say the food is good and they can choose to have what they want. Breakfast and snack meals and mealtimes are flexible and they decide daily as a group about the main cooked meal. Nobody requires a special diet and staff offer and promote varied and healthy options, such as fresh fruit, meat and fish and wholemeal bread. Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. Service users’ personal and health care needs are being met appropriately with staff support and their medicines are managed safely by the home. EVIDENCE: Service users’ plans outline the assistance they each need from staff with their personal care and in their daily lives, including moving & handling. Information in their care records includes guidance about any particular health related issues such as epilepsy. Records kept by staff show they help service users arrange to have an annual health care check and routine checks such as with a dentist, optician & chiropodist. Input from health care specialists, such as a psychiatrist is sought as needed. One service user has ongoing health problems, leading to several hospital admissions during last year. A district nurse now visits this person at the home twice weekly and a dietician has also been involved, to monitor their condition and/or support staff to manage it. Regarding medication SCOPE provides general policies & procedures for the management of medicines in all their care services and there are also specific Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 14 procedures for Exbury Place. Each service user has a written medication profile with a list of their prescribed medicines and information about their use and possible side effects. The home also keeps the Patient Information leaflets for staff reference. Service users medicines are safely stored in locked drawers in their bedrooms and records are being maintained appropriately. New staff receive instruction about medicines during their induction and then receive accredited training from an external trainer, before they are allowed to administer in the home. Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. There are systems in place to support service users and their representatives to raise concerns. Staff receive instruction and there are policies & procedures provided to help them to protect service users from abuse. EVIDENCE: SCOPE provides a formal complaints procedure and employs a Complaints Resolution Manager to investigate complaints about its care services. Service users say they know who to raise concerns with and would feel able to talk to their keyworker and staff. Two relatives say they are not aware of the home’s complaints procedure but have not needed it anyway. Since the last inspection no complaints or vulnerable adults concerns were raised with the Commission. There are relevant policies & procedures relating to protection of service users (including whistle blowing). They appropriately refer to the Worcestershire multi-agency procedures for responding to any suspicion or allegation of abuse and/or neglect of vulnerable adults. SCOPE employs an Adult Protection coordinator who provides instruction for staff about abuse and protection as part of their induction, (which a new staff member confirmed). The team leader said the staff team are to receive “refresher” instruction some time soon. In respect of service users’ finances each person has their own cash tin to keep their personal allowance in and savings accounts. Records are kept when staff deal with any money on service users’ behalf, which are signed for and audited monthly. Receipts are also kept when anything is brought for them. Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 16 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, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. Exbury Place offers service users ordinary and comfortable housing within the community that is suitably adapted and equipped to meet their special needs. There are appropriate arrangements in place for the accommodation to be kept clean, tidy and well maintained. Although one aspect would benefit from some improvement to enhance the environment and for service users’ safety. EVIDENCE: Exbury Place is a cul-de-sac situated on a large, modern residential housing estate. It is about two miles from Worcester city centre and within easy reach of the M5 motorway. There are local shops, public houses and a superstore with a café. The home has two suitably adapted vehicles, and one service user has their own car, to facilitate their community participation. The property is owned by a social landlord who lease it to SCOPE, and is an ordinary bungalow, which therefore is compatible with other housing around it. Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 17 The bungalow has been adapted for people with physical disabilities and so who could be wheelchair users. There are ramps, rails, wide doorways and corridors and other aids, such as hoists, provided. The home has a call bell system and various aids & equipment to meet individual service users needs. The home has a reasonably sized communal room with a sitting and dining area and the kitchen. The garden can be accessed through patio doors from this room and could provide a pleasant seating area and aspect. However the whole garden looks rather neglected because the paving is tatty and uneven and although the broken fence has been repaired since the last inspection, it would benefit from the slabs being re-laid and a good tidy up and/or planting. Clearly an uneven surface could also pose a risk to service users. This should be risk assessed and improvements made before the better weather arrives. The general impression of the home is homely and comfortable and the inside was seen to be clean and tidy. The sitting room has been redecorated and a new carpet fitted fairly recently and overall the premises look well maintained. Staff receive training and there are policies & procedures relating to infection control. Advice had appropriately been obtained from district nurses about one matter that could affect infection control and hygiene in a care home. Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. Service users are being supported by a full and stable staff team which is good for consistency of care. Whilst most staff are suitably experienced and have received training to help them promote service users safety, their skills and knowledge should be enhanced when more have achieved a care qualification. The home’s recruitment procedures are thorough and so should help to ensure that only suitable staff work at the home, for service users’ protection. EVIDENCE: There is now a full staff team, which is good for service users and for stability in the home. There are seven support staff, a senior and one relief support worker. A team leader is responsible for supporting this and the other two 1st Key care homes. Rotas show that two staff are always working during the day and three days a week there is an extra “flexible” staff member. The senior also has one day a week allocated specifically for administration. Although it is evident that staffing levels are sufficient to meet service users’ personal care needs, two service users feel that sometimes more staff would Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 19 enable them to go out more when they want to. Whilst staff say that they can usually accommodate service users’ requests, clearly as service users dependency is high their flexibility can be limited. Staff deployment should be discussed with service users and reviewed accordingly. In respect of staff recruitment a fairly new staff member was interviewed and described completing an application form and attending for interview. It was confirmed that a CRB check and two written references had been taken up by SCOPE. Although he had previous care experience and already undertaken all the core health & safety training he completed a four-day induction (including ethics & disability awareness) and worked some shadow shifts. Refresher training in relevant training areas is now being arranged and he has started an accredited induction programme. All new staff are expected to work a 6 month probationary before their appointment is confirmed. One new staff member’s records were checked and appropriately included two written references, one from their most recent employer, and their full employment history. Regarding training SCOPE requires staff to complete mandatory health & safety areas. Topics relating to the rights and special needs of service users are covered in their induction programme and accessed as needed. Only two staff currently hold an NVQ qualification, although two are working towards obtaining it and the two new staff doing their induction will also move onto NVQ in due course. The Standards specify at least half the staff team in care homes should hold this qualification or have experience/training to this level. Staff feel there is good communication in the team, through daily reports, shift handovers and team meetings. The new staff member was able to access all the relevant information about service users and their needs before working with them. It was observed and staff confirmed that the team works well together and they feel supported by senior staff. SCOPE also update them on issues and are supportive to the home. Staff all receive individual supervision about 4-6 weekly from the home’s senior and have an annual appraisal. Each person has a training record and SCOPE provides a format for supervision sessions to monitor their work performance and training needs, covering core competencies, objectives and leading to a personal development plan. Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including this visit to the service. The home runs well, although the management arrangements are unusual. It is positive that a system to monitor and review the quality of the service is being introduced. This should result in a plan for the continual development of the home and to improve its quality, based on what service users want. Appropriative steps are being taken to keep the home safe and to make sure that the ways staff work safeguard and promote the welfare of service users. EVIDENCE: The registered manager is Andrew Deakin, who is suitably experienced. He is currently working to achieve the Registered Managers Award, which is an NVQ level 4 and the qualification specified in the Standards for care managers. Mr Deakin is the community service manager for 1st key Worcestershire and the Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 21 management arrangements for this service are unusual as he is based at the 1sy Key office and does not run the home day-to-day. He is responsible for 1st key’s business plan, finance, service performance and policies & procedures. A team leader (also not based at the home) is responsible for monitoring the service delivery and quality at three 1st Key care homes and a senior support worker manages the home’s staff team, service users’ needs and records. The manager therefore does not spend dedicated time in the home, but does attend staff meetings and is always available to give advice and support on call. Oversight is delegated to the team leader (Rachel Hall) who visits the home at least one day a week. Ms Hall also supervises the senior, carries out staff annual appraisals and attends service users’ care reviews. In light of recent changes to how care services are to be regulated there is now an onus on registered providers and managers to self regulate. As there will be longer gaps between inspections they will be required to provide evidence to the Commission about how they are reviewing the quality of their service and promoting good outcomes for service users. Also how their quality assurance processes will result in the continual development of the service, based on the views of service users and other stakeholders. SCOPE are implemented a quality assurance system and a development plan for each service should be produced by next April. Service users will be asked to complete an annual survey, supported by a relative or advocate of their choice. Other relevant people will also be involved through such as placement reviews. The way SCOPE monitor their services will also change. The required monthly visits to check how the home is being run are now made by regional managers, however community service managers will probably carry out these visits soon. This could be a better arrangement as registered managers could demonstrate their input to the home to provide evidence that they are monitoring the way seniors are running the home on a day-to day basis. Consideration should also be given to how they communicate with the Commission. In this context the reports made following the monthly visits need to be more detailed. Currently they are brief checklists and it was noted some aspects had not been audited recently. It is good that this process and format are currently under review. In respect of health & safety all staff undertake the mandatory training as part of their induction and refreshers at specified intervals. SCOPE employ a trainer to provide training in relevant areas and there is a moving & handling trainer on the 1st key staff team. Video packages are available for instructing staff in fire safety & infection control. The pre-inspection questionnaire confirms the home has a written fire risk assessment and fire drills are arranged regularly. Information about regular servicing of equipment, gas installations & central heating and COSHH risk assessments is also detailed. The fire log showed required tests and checks were recorded as having been carried out. There were no safety hazards identified during this visit and overall it is evident due attention is paid to promote the welfare and safety of service users and staff. Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 22 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 3 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 3 29 3 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 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 23 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 persons meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered provider 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 to consider carrying out. No. 1 2 Refer to Standard YA6 YA24 Good Practice Recommendations Service users’ plans and reviews should also reflect their personal goals and social needs and the action taken to achieve their identified goals, detailing any outcomes. The garden should be cleared and made to look nicer as soon as possible. The condition of the paths and paving slabs should also be risk assessed to ensure they do not pose a safety hazard to the service users. The programme for staff to undertake NVQ training should continue so that at least half the staff team are qualified and/or it can be demonstrated that any staff not qualified are suitably experienced to this standard. The home should produce a plan with aims for the continual development of the service in the year ahead. This should reflect the views of service users and significant other people. Consideration should be given to how the registered manager could demonstrate his input to the home and ensures its effective day-to-day running. Also how this information could be shared with the Commission. 3 YA32 4 YA39 5 YA39 Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Exbury Place, 12/13 DS0000018651.V321052.R01.S.doc Version 5.2 Page 25 - 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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