CARE HOME ADULTS 18-65
12 Shenfield Way 12 Shenfield Way Brighton East Sussex BN1 7EX Lead Inspector
Jenny Blackwell Announced Inspection 27th October 2005 10:00 12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 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 12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 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. 12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 12 Shenfield Way Address 12 Shenfield Way Brighton East Sussex BN1 7EX 01273 296364 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) Brighton & Hove City Council Elizabeth Ann Bateman Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is 3. Service users should be aged between18 and 65 years on admission. Only adults with a Learning Disability who have been assessed as requiring residential care are to be accommodated. 28th April 2005 Date of last inspection Brief Description of the Service: 12 Shenfield Way is part of the South Downs Health NHS Trust and Brighton and Hove City Council joint provision of services. Kelsey Housing Association owns the building. The home provides residence and care to up to three younger adults with a learning disability. Currently the two people who have lived at the home for some time have recently been joined by a new person. The home is a detached two-storey building, situated in Brighton. The location of the home offers access to local amenities, including a food shops, pubs and cafe. Each person has their own individually decorated bedroom. Communal areas comprise of a lounge/dining room and kitchen. The people who live at the home attend local day services, and also have one to one activities during the day. 12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. During this summary and the report the people who live at the home will be referred to as people/person, and the people who work at the home as staff or by their job title. The people who live at the home, some of the staff team, deputy and manager were present during the inspection. Time was spent with all of the three people who live at the home. The manager and deputy were spoken to individually and four staff were spoken to throughout the day. The day was arranged to fit around the activities organised for the day. The requirements that were made during the last inspection were checked to see if they had been met. Some had been met in the timescale however one requirement was still outstanding from July 2004. The people who live at the home and the staff were helpful throughout the inspection and contributed to the report where possible. What the service does well:
The family members spoken to on the day praised the staff teams commitment and enthusiasm. They were confident in the manager’s abilities to lead the service and found her approachable and welcoming. If she was not available to them they said they were confident in the abilities of any of the staff to support them with their queries about their son. They found the staff to be knowledgeable and trusted the decisions they made on behalf of their son. When asked about their views about the quality of the care provided they stated, “it is a super home”. The family said that initially they had concerns over the compatibility of the person who last moved to the home. Their son had experienced some difficulty as his routines were disrupted. However they felt the staff team had worked hard to manage the situation and now felt the situation had improved. The care plans were looked at for each person. They contained information that described a person’s interest, likes, dislikes, family and friends connections, basic health and social care needs. The key workers and other staff contributed to the plans, and care was taken in the use of language when describing the people’s support needs. Staff were seen to use objects of reference, Makaton and photos, which demonstrated a commitment to supporting each person to control their day as much as possible.
12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 6 The staff team were gaining in confidence in allowing the people to take measured risks. These will help the individuals to develop practical skills, for example the staff now supported the people into the kitchen to participate in making drinks and snacks. All three of the people who live at the home have a full life of leisure activities. On the day of the inspection, one person was out at an organised day service, another went swimming and the other person had been out walking in the morning. A staff member has made some improvements around the house by personalising some areas for the people, such as one person’s bathroom had been brightened up by the staff member putting up reflective tiles, painting the bath panel and personalising the shower cubicle for him. The staff were spoken to about their roles. They had a good understanding of the responsibilities and were seen on several occasions during the day working out the planning of the day. Responsibility for monitoring different areas of health and safety is delegated to the staff members. For example one person monitors the food hygiene, another the medication and another the fire procedure. The delgated tasks are well organised and the individuals involved have responded well to the responsibility. What has improved since the last inspection? What they could do better:
12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 7 The statement of purpose and service user guide was viewed. The manager and senior staff of the organisation had amended the document since the previous inspection. Although the documents was improved the service and facilities was not fully reflected in the documents and needed further work. The home did not have a specific contract with the people at the home. The manager and inspector viewed some documents, which contained the terms of residency at the home and a contract between the housing association who owned the home and the individuals. The manager stated that the organisation was working with their registered managers to produce a clearer contract for the individuals. The staff were developing a risk assessment strategy to enable the people to live a more independent lifestyle. It was noted that this progress would need to continue to ensure opportunities for the people to develop new skills and grow in confidence. The manager and inspector talked about the removal of a keypad to the lounge door. She stated that the keypad was due to be removed as they were working towards opening up the home. This will be looked at again during the next inspection. The manager runs a transparent system of handling the people’s money. The system had an easy audit trail from receiving benefit monies to cash transactions. It was recommended that the manager check the insurance cover the organisation has for replacing cash for the people. The problem in identifying who is responsible for the home’s maintenance and decoration continues. Due to a dispute in contractual arrangements the manager was unable to identify the budget holder for decoration of the home. A requirement to address this has not been met from July ’04. The manager stated that seniors in the organisation and the housing association were drawing up a contract to resolve this. This has been a protracted exercise and will continue to be monitored by the commission, as there are concerns about the decoration in some parts of the home. The home continues to have a lot of shifts that are covered by agency or relief staff. It is required that the manager ensures the regular agency staff are appropriately supervised and have access to the staff meetings to ensure continuity of care. The organisation undertakes different audits in the home to check for the quality of service the home provides. It was not clear if the organisation and home has a quality audit tool to meet the standard. The policies are generally well reviewed and updated. It was noted that the Adult Protection policy had not been reviewed since 2000. It is recommended
12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 8 that the manager ensures that the policy the home is working towards is compliant with recent adult protection legislation and guidance. 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. 12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 9 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 12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 Prospective people would be provided with information about the home although adjustments were needed to the documents to accurately reflect the services to be provided. The people’s needs and aspirations where noted and the home could meet their needs. New people would have the opportunity to visit and try out the service. The people who live at the home do not have a contract of terms and conditions. EVIDENCE: The statement of purpose and service user guide was viewed. The manager and senior staff of the organisation had amended the document since the previous inspection. Although the documents were improved, the service and facilities was not fully reflected in the documents and needed further work. It was required that the manager ensure that the statement of purpose and service users guide accurately reflects the current service provided at the home. At the last inspection it was noted that two of the people who had lived at the home did not have social care assessments. The manager had now ensured that the two people had been assessed. The manager stated she would review the people’s care plans, along with the assessments, to ensure the individuals assessed needs are met by the home.
12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 11 Through observation, looking at records and speaking to one person’s family, evidence was gathered that the home is meeting the current people’s needs. The family said that initially they had concerns over the compatibility of the person who last moved to the home. Their son had experienced some difficulty as his routines were disrupted. However they felt the staff team had worked hard to manage the situation and now felt the situation had improved. The home did not have a specific contract with the people at the home. The manager and inspector viewed some documents, which contained the terms of residency at the home and a contract between the housing association who owned the home and the individuals. The manager stated that the organisation was working with their registered managers to produce a clearer contract for the individuals. 12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,8,9 and 10. Care plans were in place for all three people, containing information that enabled staff to provide consistent support to each person. The people are consulted on, and participate in, day-to-day decisions in their life. The risk assessment process was improved which enabled each person to move towards a more independent lifestyle. The information about the individuals was stored and handled correctly. EVIDENCE: The care plans were looked at for each person. They contained information that described a person’s interests, likes, dislikes, family and friends connections, basic health and social care needs. The physical restriction to the house, such as the hatch to the kitchen and keypads on some of the doors, were listed in each person’s care plans with risk asessments. The keyworkers and other staff contributed to the plans and care was taken in the use of language when describing the people’s support needs. The manager and team do not have a formal process of consulting the people who live at the home. The manager stated that the people’s concept levels meant that staff worked individually with people and used different communication methods to ascertain their preferences. Staff were seen to use
12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 13 objects of reference, Makaton and photos, which demonstrated a commitment to supporting each person to control their day as much as possible. The home has two staff who are currently qualifying to be risk assessors and one person trained in lifting and handling assessment. The staff were developing a risk assessment strategy to enable the people to live a more independent lifestyle. Staff were seen to support people, have access to the kitchen and the stair gate had been removed. It was noted that this progress would need to continue to ensure opportunities for the people to develop new skills and grow in confidence. The personal information about the people is stored appropriately in the home. The manager ensured that records and files about the people were locked away and staff were seen to make sure the records were put back in a secure place after that had used them. 12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 14 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,14,16 and 17 The people who live at the home were given opportunities for development and this needed to continue as the staff were more confident in taking risks. Each person had a good variety of leisure activities drawn from their preferences. The rights of the individuals where understood and respected by the staff. Some restriction around the home encroached on the people’s freedom of movement. The people enjoyed their meals and mealtimes and were offered a balanced diet. EVIDENCE: The staff team were gaining in confidence in allowing the people to take measured risks. These will help the individuals to develop practical skills. For example the staff now supported the people into the kitchen, to participate in making drinks and snacks. The staff have worked hard at supporting people to go out and participate in social activities, getting the balance between opportunity and risk right. This has not been so well achieved within the home, as historically some areas to the home have been restricted to the people who live there. To help the people to gain further life skills the manager and staff will need to continue to develop
12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 15 the participation around the home in preparing meals, laundry, and other household tasks. All three of the people who live at the home have a full life of leisure activities. On the day of the inspection, one person was out at an organised day service, another went swimming and the other person had been out walking in the morning. The plan of activities is written for each person based on their known preferences. All three men are regularly out and about in their local community and it was noted during the day that staff were well organised and ensured if an activity could not take place then an alternative was set up. The rights of the individuals are recognised by the staff team and manager. As previously stated some work has been done to improve the access around the home. A stair gate has been taken off which now allows the people to go up and down the stairs as they wish. Supervised access to the kitchen is working well with the people and needs to continue. Several keypads are used around the home to prevent access to different rooms. The layout of the home does not fully suit the needs of the current people. It is difficult for the people to have space away from each other. It was noted that meal times caused particular anxieties for the people as a lot of people were in one place. When the third person moved to the home, the staff had used keypads on some doors to keep people separated, to prevent negative interactions between the people during these times. Although this helped in the short term, the staff had not used this method of keeping people apart for some time. It is necessary for the manager and staff to be managing the shared space differently, without the need of locking people in or out. The manager and inspector talked about the removal of a keypad to the lounge door. She stated that the keypad was due to be removed as they were working towards opening up the home. This will be looked at again during the next inspection. The preparation of the evening meal was observed. The staff prepared the meal on the menu for that day. During the cooking, two of the people were in the dining area where they can see what is going on in the kitchen. Although the people did not participate in the cooking, staff were seen to chat with them and ask them about preferences about the meal using objects of reference. The portion size of the meal was good and presented well. The staff ate with the people and chatted to them throughout the meal. Two people were helped with their food by the staff; it was decided before the meal which staff would help who. The staff were sensitive to the people needs and
12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 16 paced the meal according to their preferences. One person was encouraged to clear up after his meal. The staff had utilised the space in the dining room/ lounge as best as possible to reduce the anxieties of the individuals. 12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 17 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18-20 The people received personal support from the staff in a way that was identified in their care plan. The people’s physical and emotional support needs are met by the staff and was supported by the organisation’s policies. People do not administer their own medication, as this was not appropriate. The staff followed the organisation policies and administered the medications appropriately. Although the people were young adults, work had been done by the staff team to handle the ageing, illness and death of the individuals with respect and according to their wishes. EVIDENCE: Information on how to support the people during personal care was detailed in their plans. Staff were seen to knock on people’s bedroom doors and respond respectfully when the people approached them for personal care support. The manager and keyworkers ensure that the people attend routine check ups and monitor their health through the care plans. The people are supported to have access to community health care teams and specialist support teams such as speech and language and behaviour support.
12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 18 The manager and relatives of one person are looking at the “best interest” process for one person to have some medical tests done. The manager had a good understanding of the process she would need to go through to ensure his rights were protected when being nominated for medical procedures. The relatives of the person said they work closely with the manager and felt involved with his care. Improvements had been made to the medication procedures. The organisation and manager have developed a medication policy to have one staff member administer the medication each shift. The organisation’s usual policy was that two staff are present when medication was administered. This was not practical for the team at the home as the people have 1:1 staffing which meant people could not be left whilst staff went off to do the medication. The medication system was checked with the manager present and found to be appropriately stored, recorded and administered. 12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 19 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The manager and staff were responsive to the concerns of the people living at the home. A formalised complaint procedure is in place for the home that adheres to the organisation’s policy. The organisation and manager emphasised the importance of protecting vulnerable adults, through policy, training and supervision. EVIDENCE: The complaints log was examined during the inspection. No formal complaints had been received since the last inspection and the family members spoken to had never had to make a complaint to the home. New staff to the home were instructed in Adult Protection during their induction period. All staff were expected to attend Adult Protection training, this was monitored by the manager. She ensured that people attend refresher courses regularly. Some staff spoken to did have concerns about the response that one person had to the last person moving in. Initially he could get aggressive with him and staff had discussed this as an adult protection issue. However the situation had settled and it was not an issue now. This demonstrated that staff had a broad sense of Adult Protection issues including the interaction between the people who live together in care homes; they understood that some relationships could be abusive. The manager runs a transparent system of handling the people money. The system had an easy audit trail from receiving benefit monies to cash transactions. It was recommended that the manager checks the insurance cover the organisation has for replacing cash for the people.
12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 20 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,28,29 and 30 The people are provided with a relatively homely enviroment which was safe and comfortable. The house had minor adaptions in place to support people with disabilities. The usable shared space was small and did not fully meet the individual needs. The house maintainence was undertaken by Kelsey Housing Association. The home was clean and hygienic and had improved in appearance since the previous inspection. EVIDENCE: The home is generally homely as it is domestic in size. A staff member has made some improvements around the house by personalising some areas for the people. For example one person’s bathroom had been brightened up by the staff member putting up reflective tiles, painting the bath panel and personalising the shower cubicle for him. The manager had appreciated the efforts of the staff to brighten up the home and it was noted that it made a difference to the home’s atmosphere making it a lot more homely. The home has improved greatly since the first inspection although it is still let down by the devices used to restrict some areas to the people. The keypads on the doors and bars to the kitchen make the home feel institutionalised. The manager is addressing these issues and this will continue to be monitored during inspections.
12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 21 The problem in identifying who is responsible for the home’s maintenance and decoration continues. Due to a dispute in contractural arrangements the manager was unable to identfy the budget holder for decoration of the home. A requirement to address this has not been met from July ’04. The manager stated that seniors in the organisation and the housing association were drawing up a contract to resolve this. This has been a protracted exercise and will continue to be monitored by the commission as there are concerns about the decoration in some parts of the home. The manager and staff team have been working at making the shared space of the home more user friendly. Since the third person moved to the home the staff have had greater difficulty in managing the shared space. They have taken steps to have people engaged in activities at different times of the day so that only one or two people are in the house. The home has minor adaptation to support people with physical disabilities. The staff team have developed communication methods that help the people to engage with them. The home was hygenic and the staff keep the home clean and tidy. 12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 22 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well-supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31-34. The staff were clear about their roles and responsibilities. The organisation provides training for all permanent staff. The staff team had not been wholly effective due to vacancies and sickness. The home’s recruitment procedures support and protected the people. EVIDENCE: The staff were spoken to about their roles. They had a good understanding of the responsibilities and were seen on several occasions during the day working out the planning of the day. It was not noticeable through the day which staff were relief or agency, they worked well with the individuals and used their own initiative. The family members spoken to on the day praised the staff teams commitment and enthusiasm. They were confident in the manager’s abilities to lead the service and found her approachable and welcoming. If she was not available to them they said they were confident in the abilities of any of the staff to support them with their queries about their son. They found the staff to be knowledgeable and trusted the decisions they made on behalf of their son. When asked about their views about the quality of the care provided they stated that “it is a super home”. On the day of the inspection one staff member was on a Food Hygiene training course. The organisation has a rolling programme of training and each staff member has a training plan that is looked at in supervision.
12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 23 The staffing levels were reported to have been very difficult over the summer months. Some staff had left the service whilst others were on sick leave. A staff member described the summer as the worst time in his experience as a support worker. The permanent members of staff would always find themselves as shift leaders having to organise the agency or relief staff. Since then the situation had improved with some staff returning to work. The home continues to have a lot of shifts that are covered by agency or relief staff. It is required that the manager ensure the regular agency staff are appropriately supervised and have access to the staff meetings to ensure continuity of care. It was noted that the manager and team had been flexible during this time to cover shifts. The manager works some shifts that enable her to have a good understanding of the day-to-day issues in the home. 12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 24 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39-43 The home did not have a clear quality assurance tool although audit checks such as health and safety were carried out. The people’s rights were protected by the home’s policies and procedures, which were reviewed regularly. The record keeping protected the people’s interest. The organisation and home were organised to protect the health and welfare of the people. The organisation monitors the financial viability of the home. EVIDENCE: The organisation undertakes different audits in the home to check for the quality of service the home provides. It was not clear if the organisation and home has a quality audit tool to meet the standard. It was required that the manager provides a quality audit tool to demonstrate the organisation and the home monitors the quality of service provide. A list of the home’s policies was forwarded as part of the pre inspection questionnaire. The policies are generally well reviewed and updated. It was noted that the Adult Protection policy had not been reviewed since 2000. It is recommended that the manager ensures that the policy the home is working towards is compliant with recent adult protection legislation and guidance. 12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 25 The records held in the home are suitably stored and staff adhere to the record keeping policy. The manager demonstrated knowledge of monitoring health and safety issues at the home. Staff are trained in First aid, moving and handling and food hygiene. Responsibility for monitoring different areas of health and safety is delegated to the staff members. For example one person monitors the food hygiene, another the medication and another the fire procedure. The delegated tasks are well organised and the individuals involved have responded well to the responsibility. The manager oversees the staff responsibilities The home had appropriate fire protection procedures. The home was generally a safe environment for the people who live and work in. The organisation monitors the financial viability of the service. The manager is a budget holder although as previously stated some areas of control i.e the maintenance and decorating fund is not clear. 12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 2 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X X 3 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 X 16 2 17 Standard No 31 32 33 34 35 36 Score 3 3 2 3 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
12 Shenfield Way Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score X X 2 3 3 3 3 DS0000060274.V249697.R01.S.doc Version 5.0 Page 27 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. 1 Standard YA1 Regulation 4(1) Timescale for action It was required that the manager 31/12/05 ensures that the statement of purpose and service users guide accurately reflects the current service provided at the home. It was required that the manager ensure each person has a contract with the home. It is required that the manager identify the budget holder for the home and produce a redecoration programme (Not meet from 20/07/04) It is required that the manager ensures that agency and relief staff are appropriately supervised and have access to the staff meetings. It is required that the manager provides a quality audit tool to demonstrate that the organisation and home monitors the quality of service provide. 31/01/06 27/10/05 Requirement 2 3 YA5 YA24 5(1)(c) 23(2)(b) 4 YA33 18(1)(b) 31/01/06 4 YA39 24(1-3) 31/01/06 12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA40 Good Practice Recommendations It is recommended that the manager ensures that the policy the home is working towards is compliant with recent adult protection legislation and guidance. 12 Shenfield Way DS0000060274.V249697.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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