Inspection on 17/07/07 for 150 Community Drive

This inspection was carried out on 17th July 2007.

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

150 Community Drive 05/12/06

150 Community Drive 02/12/05

150 Community Drive 04/07/05

150 Community Drive 21/02/05

150 Community Drive 19/07/04

150 Community Drive 06/01/04

Similar services:

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

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

CARE HOME ADULTS 18-65 150 Community Drive, Smallthorne Stoke-on-Trent Staffordshire ST6 1QF Lead Inspector Irene Wilkes KEY Unannounced Inspection 17th July 2007 09:30 150 Community Drive, DS0000008212.V341120.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 150 Community Drive, DS0000008212.V341120.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. 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 150 Community Drive, Address Smallthorne Stoke-on-Trent Staffordshire ST6 1QF 01782 839349 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) communitydr@choiceshousing.co.uk Choices Housing Association Limited Mrs Gillian Hussey Mrs Sally Ann Pritchard Care Home 8 Category(ies) of Learning disability over 65 years of age (8), registration, with number Mental Disorder, excluding learning disability or of places dementia - over 65 years of age (8) 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th December 2006 Brief Description of the Service: 150 Community Drive is a large detached house registered to provide accommodation for eight younger and older adults who have Learning Disabilities, or Mental disorders other than Learning Disability or Dementia. It is situated close to local shops on the edge of a residential estate, and is not identified by any stigmatising signs, names, or notices, and easily blends into the locality. Public transport buses pass the end of the Drive. The home is owned by Choices, a company that operates a group of homes for people with Learning Disabilities. The current group of residents are all male, ranging in age from their early fifties to early eighties. They live on two selfcontained floors, each housing four residents. There are generous communal areas inside the property, and a secluded garden outside, where some of the residents have established an allotment, as well as the usual lawns and shrubs. Young plants are tended in the greenhouse, which was renewed last year. Charges for the service ranged from £410 per week to £809.60 per week (07/08 prices). 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection. This means that all of the national minimum standards that the commission for social care inspection consider most greatly affect the health, safety and welfare of the residents were looked at. The inspection took place over a seven-hour period. Five of the residents were at home at different times in the day and they were spoken to both as a group and individually to gain their views about living at the home. 6 resident survey forms were returned, and 4 survey forms were received from relatives. The manager, her deputy and a care worker were on duty and each contributed to the inspection process. The inspection included examining a sample of 3 residents’ files and a sample of health and safety documentation including maintenance records and the records relating to fire safety. The arrangements for administering medication were looked at as well as the arrangements for safeguarding residents’ finances. The menu plan for the week was seen. The recruitment procedures were looked at as well as the training provided to the staff. This included inspection of 3 staff files. A tour of the home was undertaken. What the service does well: All the residents liked living at the home and liked all of the staff. ‘They’re a good bunch.’ Residents lead an enjoyable lifestyle linked to their individual interests. The life that they lead is based on their real choices. ‘They always ask me if I want to do something. I tell the staff if I want to do something.’ ‘Sometimes the staff have to help me and give advice and information to help me make some decisions. Staff write appointments in my diary to help me remember and also write messages in my room to help with this.’ Relatives spoke highly of the staff at the home. ‘Since my son has been at the home he has definitely broadened his horizons.’ ‘They help my relative keep in touch every week by phone.’ 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 6 ‘I like the way they brought him to X’s funeral and the family tree they did with him and the photos that they asked for.’ ‘I’m very happy about the way X is being looked after.’ ‘They meet all X’s needs.’ Residents are really empowered. They are involved in decision making in the home such as meal planning. They were aware of how to complain and said that staff helped them in this. ‘Yes, I have made complaints in the past. Staff supported me with this, then spoke with me to see if I am happy with the result.’ The residents’ health care needs were being met. Residents attend routine health checks and are supported to keep any health care appointments. The manager makes sure that the staff are fully aware of how any new health needs will affect the individual, and the staff receive training to ensure that the right support is provided. A comment made by a Practice Nurse was seen which said: ‘The gentlemen living at Community Drive have their health needs met to a very high standard. All the gentlemen are treated with respect and their changing needs responded to in a rapid manner.’ The home has a small staff team and there is a low turnover of staff. There is enough staff on duty at each shift to meet the needs of the residents. The staff spoken with were committed and motivated to assist the residents with a varied lifestyle that promoted their rights. Staff had received all of the training that would be expected, including specialist training to meet the individual needs of particular residents, such as visual awareness, a session on acquired brain injury, and training about particular behaviours. The manager is well qualified and is committed and enthusiastic with a ‘can do’ approach. Staff said that she has an open and approachable management style. Relatives appreciate the way that the home is run: ‘They’ve always sorted any concerns I’ve had and come back with answers for me.’ Another said ‘It’s a good home all round.’ The manager ensures that residents, families and staff are consulted about the service to see where any improvements are required. 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 7 The manager ensures by her practices that the health, safety and welfare of the residents are promoted, but does not rest on her laurels but is constantly seeking ways in which the service can be improved further. 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. 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can be assured that the home will have assessed their needs thoroughly before offering them a place at the service. EVIDENCE: No new residents had been admitted to the home, but the files of the residents showed that appropriate assessments had been undertaken looking at individual needs, strengths, choices and wishes for the future. There was evidence that other professionals and significant others had been involved in the assessment process. The last resident to be admitted to the home some 2 years ago said in a returned survey form that he had been given a booklet about the house and staff, that he made several visits before moving in and that an advocate, his mother and a social worker were all involved in supporting him when the home looked at his needs and before he made his choice about living there. Each resident had a care plan developed from the needs assessment. Regular reviews are undertaken and if there is any change of need this is recorded and the care plan amended as required. 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives and play an active role in planning the care and support that they receive. EVIDENCE: The care plans looked at had each been developed with the individual and were based on a full up to date and detailed assessment. The plans were person centred and focused on each person’s strengths and personal preferences with full information about the support that they require and their aspirations for the future. The person centred plans talked about likes and dislikes of the individual, qualities and contributions, experiences and achievements, and what makes a good and a bad day for the individual. The plans had been signed by the residents who were aware of their care plan, and there was evidence of regular review. They were written in a very positive and enabling style. 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 11 The home has a clear focus on respect for residents to make decisions about their lives, with staff providing assistance where needed. 1 resident explained how he was now able to go out independently after raising with the manager that he was not happy with having to be escorted. A strategy was worked out with him to minimise risk but to enable him to make his own decisions. An advocate also became involved to check that he remained able to make his own life choices on any other issues. 2 residents are members of the ‘Reach Parliament’ – a local self-advocacy group that campaigns for the rights of people with a learning disability. 1 resident wrote in the survey form ‘sometimes the staff have to help me and give advice and information to help me make some decisions. Staff write appointments in my diary to help me remember and also write messages in my room to help with this.’ Another resident said: ‘They always ask me if I want to do something. I tell the staff if I want to do something.’ Residents are supported at various levels to manage their finances. The reasons for and the manner of support were documented and reviewed. Each resident had a financial budget plan that they had been involved in developing. The issue highlighted above about accessing the community alone is a good example of how the staff enabled residents to take responsible risks within a risk assessment and risk management framework. Clear control measures had been put in place to minimise the risk as far as possible. There was clear evidence for other residents that any risks associated with their daily life activities were discussed with them, with full discussion about personal safety and risk management strategies being agreed. 150 Community Drive, DS0000008212.V341120.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): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are able to make choices about their lifestyle, and are supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: There was a wealth of evidence to show that residents take part in activities of their choice linked to their age and peer groups. Some of the men had part time paid jobs with Choices organisation that manage the home; others chose more vocational interests such as craft groups, membership of the local residents group and a range of other occupations such as membership of ‘Headway’ group. 1 of the residents assists with the induction of new staff at Choices headquarters by talking to them about what it is like for someone to move into a care service, and his life experiences since moving to live at Community Drive. 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 13 At the inspection there were comings and goings throughout the day of residents. Some went shopping in the village independently, one went into Hanley, some one else went out for lunch and another shopping with staff. There was evidence in the care plans seen of a range of community activities being enjoyed, from meals out, drinks, going to church, craft groups and bingo, to involvement in the local residents group. A range of transport is available to the men, including Choices own transport, taxis and public transport. Staff rotas are flexible to allow staff time with residents outside the home, including evening and weekends, although a number of residents also go out independently at these times. 1 relative responded in a survey form: ‘Since my son has been at the home he has definitely broadened his horizons.’ Care plans showed that residents are supported to maintain family links and friendships outside the home. There was evidence of family visiting Community Drive and of individual gentlemen visiting their relations, often travelling independently by taxi. There was also evidence of friends visiting and holidays being taken with friends from other Choices houses. Another gentleman went to activities at the ‘Headway’ group and had been on holiday with them recently. Someone else is closely involved in the church that he has always attended before moving into care, and friends from the church collect him and take him to various church groups that he is involved in. Relatives’ comments included ‘They help my relative keep in touch every week by phone.’ ‘I like the way they brought him to X’s funeral and the family tree they did with him and the photos that they asked for.’ The daily routines of the house are flexible to meet the individual choices of residents. At the inspection some residents were finishing their breakfast, some were in the lounge, others had gone out and were preparing to go out, and a couple were in their bedrooms. Staff were seen to knock at bedroom and bathroom doors and waited for permission before entering the bedroom. Residents had their own bedroom and front door keys. Throughout the day staff were heard conversing with residents and treating them as equals. 2 residents confirmed that the gentlemen get together on each floor and plan the menus for the week. They also said that if they changed their minds about what was on the menu that was no problem and they made their own choice again about what they wanted. The menu plans were seen and the manager said that a dietician had visited the home to advise both the staff and the residents about healthy eating. 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 14 One of the gentlemen has just found out that he needs to follow a gluten free diet, and it has been arranged for the dietician to visit again to advise on this. The staff were heard discussing with the resident about going shopping together to get some food for him and they talked about a variety of branded foodstuffs and varieties to find out what he would enjoy. The fruit bowl in each flat was full of a variety of fresh fruit. The fridges were well stocked with perishable goods. 150 Community Drive, DS0000008212.V341120.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): Standards 18, 19 and 20 Quality in this outcome area is excellent. This judgement has been made using available 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: Care plans showed clear information for staff about the way that individual residents preferred to be supported. Residents are encouraged to be independent but where some support is required this is provided in a sensitive way. Staff were discreetly listened to talking to residents and encouraging them by prompting to present themselves well when going out into the community. Such discussions were made in a way that was positive and never demeaning or patronising, and the residents responded well to the encouragement. Residents confirmed that they made their own choices about getting up, going to bed etc. and the care plans recorded the residents choices about when to have a bath or shower. People were dressed individually according to their own particular tastes. 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 16 The home has a walk in shower and an assisted bath. No other technical aids are needed at this time. A staff member was asked about the support needed by a resident who she is key worker to. She had a good understanding of his needs and awareness of the need to promote individual choices. The home does not currently have any male staff. There was evidence in a resident’s file that he had enjoyed the company of a male member of staff previously and he confirmed that a mixed staff team would be good. The manager said that senior managers had been made aware of the desire to recruit male staff into the home, and it is hoped that this is pursued for the next vacancy if at all possible. Residents had been supported to attend appointments across the full range of healthcare professionals, including the GP, district nurse, a hospital consultant, and various clinicians, both locally and at various health centres, and with support and transport where necessary. Visits to see the optician, the chiropodist, the dentist, and specialists in hearing loss were recorded. Each man is registered with a G. P. surgery and was recorded as having Well Man annual health checks, as well as flu and pneumonia vaccinations. Staff receive comprehensive training to help their understanding of the health and personal care support needs of the residents, i.e. specialist training in visual awareness. The manager has arranged for a nurse to visit the home to inform staff about testicular checking, and then it is hoped that staff can pass this knowledge on to the gentlemen to enable them to undertake their own checks. Residents have individual health profiles and action plans. Health assessments are conducted on an annual basis to cover the whole range of physical and mental health, and these have been reviewed with external health professionals. There were various records of how any challenging behaviours should be managed, accompanied by a clear risk assessment and behavioural and emotional care plan. There was a record of a compliment from a practice nurse who had said: ‘The gentlemen living at Community Drive have their health needs met to a very high standard. All the gentlemen are treated with respect and their changing needs responded to in a rapid manner.’ Relatives commented: ‘I am very happy about the way X is being looked after.’ ‘They meet all X’s needs.’ 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 17 The arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines in the care home were robust. There was a homely remedies list that had been signed by the GP. The care plans carried an up to date list of all medication for each individual resident and there was information available about the medication to inform staff. 2 residents are supported to partly self medicate. Evidence was seen of appropriate risk assessments for self-medication. One resident said that he liked the independence of being responsible for his medication. He said that staff checked with him that he had taken it. 1 gentleman is on a course of medication currently where there are weekly changes in the dosage required. The manager and deputy had introduced sound procedures to control this and there was regular auditing of the medication and checks in place to ensure medication safety. Staff have all received training in the administration of medication. The manager confirmed that the training received was appropriate to the complexity of the medication that they provide support with. Staff also undertake periodic competency checks for medication. 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to express their concerns via a robust, effective complaints procedure. They are protected from abuse, and have their rights protected. EVIDENCE: The home has a clear complaints procedure that is availanble in a wide variety of formats, linked to the way that the individual resident prefers information to be shared with him. There is a copy of the complaints procedure displayed in the entrance hall. There was evidence that the procedure for making a complaint is explained to residents and relatives and any complaints are responded to in 28 days. A resident said: ‘Yes, I have made complaints in the past. Staff supported me with this, then spoke with me to see if I am happy with the result.’ The complaints log showed a number of complaints between resident and resident living at the home. No other complaints had been received. Some of the complaints recorded the action that had been taken to respond to the complaint and the outcome, but others did not. However, the manager was able to demonstrate in those instances what action had been taken to resolve the complaint. It is recommended, however, that the complaint log be used to 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 19 show the investigation and final outcome of the complaint in all instances, including relevant dates. The commission has received no complaints about this service. The manager plans in the next 12 months to quantify the number of in house complaints and how these have been resolved via team reviews and the annual quality report, showing a positive approach to learning from incidents that arise. The policy of Choices for ensuring that residents are safeguarded from abuse or self-harm has been seen previously and is appropriate. Staff records showed that all staff had received training in safeguarding adults’ procedures via in house training. There have been no reported incidents of abuse and residents confirmed that the staff treated them well. During team meetings the manager discusses with staff about the management of behaviours and de-escalation techniques and the staff are aware of triggers that may impact on behaviours for individuals, and how to manage these. Restraint is not used in the home, although the manager has this training. A psychiatrist has provided training to staff linked to 1 resident and the understanding of his behaviours. The financial records of 1 resident were sampled. The records were clear and up to date with sound monitoring systems in place to safeguard against any abusive practice. 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 26 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: A tour of the accommodation was undertaken. The home is well situated on a busy road in a residential area close to shops, health centre, community centre etc. The property is indistinguishable as a care home. 2 of the residents have actively campaigned, firstly by a self-advocacy group, and then as part of the local residents association, for a pelican crossing on the road. They were informed on the day of the inspection that whilst finance was not available for this, speed calming measures were going to be introduced on the road as a direct outcome of their campaigning. 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 21 The garden area is fenced and there is a greenhouse that one of the residents who is keen on gardening tends. Internally the accommodation comprises of 2 self contained flats, each accommodating 4 residents. Sky television has been installed in the last 12 months following requests from the residents. The whole of the premises were safe, comfortable, bright and cheerful, well decorated and with good quality furnishings and fittings. The home has a planned maintenance and renewal programme for the premises, with records kept. The majority of the residents’ bedrooms were seen. They were all well personalised and reflected the tastes and interests of the individuals. Each was well decorated with good quality furniture and fixtures, covered radiator, wash basin, and well fitted and good quality carpet. None of the bedrooms have ensuite facilities, although they are well positioned and close to bathrooms. Residents have keys to their bedrooms with appropriate locks. Hot water from a bathroom sink was over the recommended temperature levels at the last inspection. The manager confirmed that this has been recrified and that regular temperature checks are made. The laundry has been refurbished within the last 12 months. There were appropriate laundry facilities and a cupboard for storing COSHH (Control of Substances Hazardous to Health) items, which was appropriately locked. There were systems in place for controlling the spread of infection. The whole environment was very clean and hygienic throughout. 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are adequately vetted, well trained and skilled to support residents and to support the smooth running of the home. EVIDENCE: Staff were discreetly observed interacting with the residents, who also confirmed that staff are approachable and that they could talk to them. There was clear evidence of a learning culture within the home where staff receive appropriate training to enable them to meet any individual and new needs that present. Throughout the visit staff were observed interacting with the residents and there was a good rapport between them. 1 staff member is currently undertaking NVQ (National Vocational Qualification) Level 2, and the remaining staff team are qualified, ranging from NVQ2 to NVQ4. The staff rotas were flexible dependent on the needs and activities of the gentlemen but generally comprised of 3 staff on duty in a morning, 2 in the afternoon and 1 at night. The manager said that at each staff meeting the 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 23 rotas are discussed to check with staff if needs are being met by the deployment of staff. At the inspection the numbers of staff on duty tallied with the rota. A waking night staff had been introduced due to increased needs. Staffing levels seemed sufficient to meet needs. There were low levels of staff turnover. On occasions when agency staff were used such staff are well known to the men on the majority of occasions. Currently there are only female staff working at the home and the gentlemen would benefit from the addition of male staff. Regular staff meetings were evidenced. There are open team reviews with tasks delegated to empower staff. The staff meetings look at the individual needs of the men, quality issues about how the service can be improved, and there is always a topic about ensuring safety. The agendas and minutes taken of the meetings evidenced all this. The staff files seen evidenced that sound recruitment procedures are followed. Each staff files had 2 references, evidence of a full employment history being obtained, and a CRB (Criminal Records Bureau) check. Staff are employed under the General Social Care Council Code of Conduct and given copies of the code. All staff receive a statement of terms and conditions. Appointments are subject to a 3 month probationary period. The head office conducts recruitment of new staff. The dates for the receipt of the POVA First (Protection of Vulnerable Adults) or CRB were not always available on the file and it is recommended that these dates be kept locally to enable a clear audit trail. It would be good practice to find out from residents if they wish to be involved in any formal recruitment and selection of staff for this home, and to support them with training to enable this. This would build on the good practice of involving one of the residents living at the home in the staff induction procedure. In this way residents would be having a real choice in the decision making process. The organisation is asked to consider this. Staff at Community Drive are well trained. Choices organisation provides induction training to Skills for Care common induction standards. It is an accredited trainer for LDAF (Learning Disability Award Framework). New staff undertake this following induction, and the course has now been rolled out to established staff that wish to take it. In addition to mandatory training the staff team has received further specialist training to enable them to meet the needs of the gentlemen at the home. Such additional training includes visual awareness, a session on acquired brain injury, and a session on advice about testicular checking is planned. 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 24 In the last 12 months the manager has developed team training plans and undertaken an analysis of specific training needs through the use of a training and development tool. 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect and there are effective quality assurance systems in place that have been developed by a qualified, competent manager. EVIDENCE: The home benefits from a qualified, competent and experienced manager. She has NVQ 4 and the Registered Managers Award, as has the deputy manager. The manager was enthusiastic and committed. Staff said that she had an open and encouraging management style. It was clear from minutes of meetings and the way that the home is run that everything is done for the benefit of the residents. The manager expects high standards from staff and the evidence shows that staff respected her approach. There is a ’no blame’ culture but the 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 26 manager uses any shortfalls noted in the provision of the service as a learning tool for the staff team collectively to find a solution to. There is a ‘can do’ approach. There is a low turnover of staff. Residents said that they like the manager. There was a good atmosphere. 1 relative said: ‘They’ve always sorted any concerns I’ve had and come back with answers for me.’ Another said ‘It’s a good home all round.’ The manager talked about the additional training that she has undertaken, such as person centred thinking training. She co-ordinates the induction training for new staff. The organisation holds the Investors in People award. A senior manager from Choices organisation further monitors the performance of the home. The manager could demonstrate that the home has effective quality assurance systems in place. There is a clear link through planning, action and review, from individual care planning meetings to residents meetings, staff meetings, individual supervision and appraisal sessions, the development of training plans, annual quality report and audits of the service. There was evidence that residents and their families are regularly consulted. Residents receive a random questionnaire every 6 months, in addition to their views sought as highlighted above, on an annual basis. Relatives receive questionnaires about the service. From all of the feedback gathered new targets for improvement are set and their outcomes reviewed on a quarterly basis. The home could now look to expand this further by seeking the views of significant others, such as voluntary organisation staff, people who are involved with the gentlemen from the community, health centre staff to further drive forward the quality agenda. Records for residents showed that there were safe moving and handling techniques used in the home. Staff were appropriately trained in moving and handling. The home’s policies and procedures and practices in fire safety had been discussed with the fire officer. From the implementation of his advice, fire safety in the home meets the requirements of current legislation. Additions of sensory light/buzzer and vibrator alerts under pillows have been made to the fire system for 2 residents. All fire records were up to date. There were individual evacuation plans in place for each resident. There was an appropriate policy in place for dealing with an emergency. There were risk assessments in place for the environment and there were no obvious hazards noted on a tour of the home. 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 27 COSHH (Control of Substances Hazardous to Health) items were appropriately stored in a locked cupboard. There were data sheets in place for all COSHH substances. PAT (Portable Appliance Testing) was up to date. A sample of maintenance records, such as gas installations and the bath hoist showed these had been recently tested. 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 28 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 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 4 X X 3 X 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 29 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. 1. Refer to Standard YA22 Good Practice Recommendations Ensure that the complaint log shows the investigation and final outcome of the complaint in all instances, including relevant dates. This will provide a clear audit trail to show that all complaints have been addressed and acted upon where relevant. Find out from residents if they wish to be involved in any formal recruitment and selection of staff for the home, and support them with training to enable this. This would build on the good practice currently in place and would further empower residents to be involved in decisions that affect their lives. Obtain the dates for the receipt of the POVA First (Protection of Vulnerable Adults) and CRB checks for each staff member in every instance and record these on their file. This will enable a clear audit trail. Seek the views of e.g. voluntary organisation staff, people DS0000008212.V341120.R01.S.doc Version 5.2 Page 30 2. YA34 3. YA34 4. YA39 150 Community Drive, who are involved with the gentlemen from the community, health centre staff towards gathering more information about the ways in which the service could be further improved. 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Local Office 1st Floor, Ladywood House, 45-56 Stephenson Street Birmingham B2 4UZ 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 150 Community Drive, DS0000008212.V341120.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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