Inspection on 17/10/06 for 151 Valley Road - Leonard Cheshire Disability

This inspection was carried out on 17th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

151 Valley Road - Leonard... 21/08/07

151 Valley Road - Leonard... 01/02/06

151 Valley Road - Leonard... 07/07/05

151 Valley Road - Leonard... 17/02/05

151 Valley Road - Leonard... 24/08/04

151 Valley Road - Leonard... 24/02/04

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Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 151 Valley Road 151 Valley Road Lillington Leamington Spa Warwickshire CV32 7RX Lead Inspector Jean Thomas Key Unannounced Inspection 17th October 2006 10:30 151 Valley Road DS0000004221.V314737.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 151 Valley Road DS0000004221.V314737.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. 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 151 Valley Road Address 151 Valley Road Lillington Leamington Spa Warwickshire CV32 7RX 01926 881612 01926 881612 sarah.hyde@Ic-uk.org www.leonard-cheshire.org.uk Leonard Cheshire 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) Mrs Sarah Jane Hyde Care Home 4 Category(ies) of Learning disability (4), Physical disability (4) registration, with number of places 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2006 Brief Description of the Service: 151 Valley Road is a purpose-built four-bedroom bungalow that is operated by the Leonard Cheshire Foundation, a registered charity for people with physical and learning disabilities. The property is owned Warwickshire County Council and all beds are purchased and funded through Social Services. The home provides respite care (and day care) for adults with profound and multiple disabilities. 24-hour care and support is offered to four people at a time for short breaks of between two and five days. Longer visits are possible in the case of family holidays. Service users live at home with their families and visits to Valley Rd give carers a break and extend opportunities for service users to become more independent. The home is situated approximately two miles from Leamington Spa town centre and is within easy walking distance of local shops, pubs, library, church and health and community centres. There are four single bedrooms and two have en-suite facilities. The large flat garden is mainly lawned and includes a sensory area complete with mobiles and touch sensitive items. There is ample parking space to the front of the property. Information provided by the manager indicates that the home’s fees that are paid by Social Services are in the region of £180,000 per year. 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. In terms of the context for the inspection, it should be noted that throughout the report, service user represents those who are being cared for and the Home refers to 151 Valley Road. Where reference is made to the standards and the regulations this means the National Minimum Standards for Care Homes for Adults (18 – 65) and The Care Homes Regulations 2001, respectively. This visit was unannounced and took place on Tuesday October 17th 2006 beginning at 10.30am and finishing at 5.40pm. The home was providing regular short stays for 17 service users and at the time of the inspection, three were staying at the home. During the visit, records and documents were examined, an opportunity was taken to tour the premises and staff working practices were observed. Two staff and the manager were spoken to. Due to the nature of the service users’ disabilities, it was difficult to talk to them but observations enabled the inspector to gain a better understanding of how the needs of service users were being met. On the day of the visit, service users were out attending daycare and returned to the home at approximately 3 p.m. 10 questionnaire surveys were sent to service users and their relatives. At the time of writing this report, three had been completed and returned to the commission. Comments noted include: We have been around the home I think three or four times, altogether, and it appears to be clean tidy, and very respectable. From the outset, we were very impressed and seemed at peace and relaxed and happy. He appears to have the support he needs. First-class establishment staff always helpful and friendly. An audit of the surveys found that staff listen and act on what is being said and they are usually available. Not everyone was aware of the complaints procedure but would complain if dissatisfied with any aspect of the service. Service users’ received the medical support they need and activities are sometimes available. 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 6 Since the last inspection on February 1st 2006, we have not received any complaints; allegations of abuse or concerns and none have been received by the home. What the service does well: What has improved since the last inspection? What they could do better: Make sure new employees do not work with vulnerable adults until information necessary to determine their fitness to work has been secured. For example, receipt of a Criminal Record Bureau (CRB) disclosure and checks made against the Protection of Vulnerable Adult (PoVA) register. To facilitate data protection and access to records, details of information recorded when the manager visits prospective service users and their carers must be held in the service users’ personal record File. 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 7 To monitor the service the Registered Person or delegated person must visit the home monthly and write a report on the conduct of the care home. A copy of this report must be available for inspection. The quality monitoring and assurance system must be further developed to include consultation with parents, health and social care professionals and other stakeholders and used to contribute to the annual development plan. 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. 151 Valley Road DS0000004221.V314737.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 151 Valley Road DS0000004221.V314737.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users make several visits to the home including an overnight stay before moving in for a short stay. A comprehensive care needs assessment is undertaken to identify whether the home is able to meet the individuals needs. EVIDENCE: The manager talked about the initial care needs assessment and the arrangements for service users to move into the home for a short stay to enable their carer to have a short break. Prospective service users visit the home before a decision is made as to whether the home can meet their needs. Visits to the home are planned and start with what is known as ‘tea visits’ this is when the service user visits for a short period during the day and stays for tea. A longer stay that includes an overnight follows. This helps the service user get to know the staff, the layout of the home and the location of their own room. Staff use this time to get to know the service user and to learn more about their daily routines. These visits also enable staff to further identify and develop effective communication methods and techniques so that they can respond appropriately to service users’ needs. 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 10 Examination of the initial care needs assessments of two service users showed that detailed information had been provided by the agencies involved in the provision of care and (if appropriate) education. For example: speech and language therapist, physiotherapist, the school and the referring agency Social Services. The manager said she visits prospective service users and their parents in their own home to clarify care needs and to agree how needs are to be met. Records read confirmed this happens. Admission to the care home is not agreed unless service users’ meet the agreed criteria and the home is sure care needs can be met. 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 11 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided with the information they need to meet service users’ needs and goals safely and consistently. EVIDENCE: Each service users has a plan of care and written information about their needs. Two care plans were read and confirmed that generally sufficient information is in place regarding service users’ personal routines, likes and dislikes and personal needs. This is particularly important to enable staff to respond to people’s needs in a person centred way, as all the current service users are not able to communicate their needs to staff verbally. Service users files also contain information to assist staff to understand each person’s individual gestures and signs that form the means by which they communicate their needs and wishes to staff. This has included the involvement and advice from a speech and language therapist for one person. Multi-disciplinary review notes were seen in service user’s files as evidence that their needs are being 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 12 regularly reviewed with the involvement of health professionals involved in their care. Service users are supported to take acceptable levels of risk in their day-today lives, any risks to service users are assessed and clear action to reduce any risks are recorded. For example, the staff to carry out regular observations at night of a service user at risk of having seizures while sleeping. A behaviour management plan was in place to reduce risk to the individual and others who may be affected by any ‘disruptive‘ behaviour. Staff are able to describe the content of care plans and risk assessments and showed an understanding of each service user’s needs and risks. They were observed being respectful, caring and sensitive to each persons individual needs. Observations showed staff talking to service users about their needs and responding appropriately to individual methods of communication for example: providing biscuits and a drink for a service user who they said wanted some food. Notes of the managers visits to a prospective service user including details of the service user’s care needs and personal circumstances were not held on the service user’s file but in a book that also held information about the home. This issue was raised with the manager who demonstrated a commitment to making sure information is held on the service user’s file and protected. Staff said service users are well cared for and have their individual needs met appropriately. 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 13 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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported in the local community and take part in activities. Their rights are respected and they have a varied and balanced diet. EVIDENCE: As service users are at the home for only a few days at a time, staff try to make sure service users follow their usual daily routines. Information about hobbies and interests are recorded in the care plan and records held include likes drawing and entries made confirm this activity happened along with the following: made some scones played on computer chose to stay here in her room. Due to the long distance, four service users from the Stratford area (who regularly stay at the home for seven nights every month) are unable to attend 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 14 their regular day-care therefore; the home provides a similar service for the duration of their stay. Various games and musical instruments are available as well as a sensory room, which was out of order and awaiting repair. The garden is accessible and has a gazebo, summer house, water feature and large sensory board both of which can be easily activated by pushing various buttons. Work to relocate an electric cable was underway and the area screened off until work has been completed. Bedrooms are fitted with various accessories such as televisions and music players. Service users bring personal items into the home with them that bring comfort or remind them of home. Staffing levels enable service users to be supported in the community and attend activities suited to their needs. Voluntary donations made to the organisation and local fundraising activities fund many of the activities including trips out. For example visits to McDonalds, Hatton Locks for lunch and Draycott Water to feed the birds. A number of service users also visit a nightclub in Leamington Spa 6:30pm to 9:30pm once each month and specifically arranged for people with a learning disability. Each service user as a communication diary that holds regular entries made by both relatives and staff, which provides a useful method of communication. Information about how the service user spends their time and whether they have enjoyed their food is included in the entries made. The diary provides carers and parents with some insight into how their relative is being cared for. The manager talked about introducing new picture diaries which would make the information more accessible to service users. One picture diary had been devised and was interesting and informative. For instance, the dairy held a range of colourful illustrations reflecting a visit by the service user to St Nicolas Park in Warwick. Throughout the inspection, staff were seen to be respectful, kind, and relaxed in their manner and were patient and considerate at all times. For example, staff switched the music off at a mealtime. This promoted a calm and pleasant environment in which service users could relax and enjoy eating their food. The atmosphere throughout the meal was relaxed and service user focused. All foods are prepared with the knowledge of service users likes and dislikes. Drinks and snacks were offered when the service users arrived home from day-care. A record of all foods eaten are recorded and monitored to ensure service users receive a healthy and balanced diet. Menus are held and show service users are offered a nutritious and balanced diet. On the day of the visit, sausage casserole or toad in the hole was on the menu. The service users were unable to express an opinion about their preferences so the staff used their knowledge of the individuals including their personal likes and dislikes when deciding which dish should be prepared. The food served to the three service users was suited to their individual needs and included a liquidised, soft and one plate of food cut up. Staff were encouraging and 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 15 supportive throughout the process and assisted two service users to eat their food. Service users were observed as being relaxed, happy and responded well to staff. 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is offered to service users in such a way as to promote and protect their privacy, dignity and independence. Medicine is administered and stored safely EVIDENCE: The sample of service user plans seen at the home showed that staff have comprehensive information about the personal care and health needs of each service user. Staff spoken with said that new members of staff receive instructions about how to assist each service user and their practices observed before they assist a service user alone. Discussion with the staff found they had a good knowledge of how service users preferred to receive personal care. Service users require significant support to meet their personal care needs, including mobility, and the level of support required is identified on the care plan with an emphasis on maintaining and promoting independence. 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 17 Service users have access to healthcare services to support their assessed needs and this includes psychology services, learning disability nurses, general practitioners, optician and dental services. The health needs of service users are monitored on a daily basis and appropriate action and intervention is taken when necessary. Medication was seen to be stored appropriately in the home and an observation of a member of staff giving medication to a service user demonstrated that this was done accurately. Records of medication administered were in good order. Boots the chemist provide suitable training for staff responsible for administering medication. 151 Valley Road DS0000004221.V314737.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): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Relatives and service users are assured they are listened to and complaints are dealt with appropriately. Rigorous staff recruitment policies and procedures are not always followed and may therefore place service users at risk. EVIDENCE: The home has complaints policy and procedure, a copy of which is available in pictorial format. The people using the service have profound disabilities and complex care needs and are unable to use the procedure. The home makes available details of independent advocacy services and always ensures an advocate is requested to attend any reviews. There have been no complaints or allegations of abuse made to the home or received by the commission since last inspection. Staff knew and understood the complaints policy and felt confident that any issues they had would be dealt with appropriately. Examination of the staff-training matrix confirmed staff had received training on adult protection awareness. The manager talked about staff training on abuse and said she delivers abuse training in the region and all staff are issued with a workbook for the Protection of Vulnerable Adults. Staff demonstrated an excellent understanding of abuse issues and knew what to do if they 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 19 suspected any. Staff talked about the types of possible abuse and highlighted subtle forms of abuse, for example, not having the heating on during cold weather. The home’s policies and procedures safeguard service users from potential financial abuse. Carers sometimes leave small amounts of money at the home to pay for any items purchased on behalf of the service user. Anyone bringing money into the home is issued with a receipt. Money is held separately and securely in the service users own room. Any expenditure is documented and receipts given to the service user or their carer. 151 Valley Road DS0000004221.V314737.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): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a safe, clean and homely environment. EVIDENCE: The property is owned and maintained by Warwickshire County Council and the staff are employed and supervised by the Leonard Cheshire foundation. The home has four bedrooms that are all decorated in different colours and furnished and equipped to meet the needs of the service users. The home has a warm and homely atmosphere. In addition to bedrooms, service users can use a sensory room, (which also doubles as a sleeping in room for the night support worker), conservatory, dining room and a bright and spacious lounge. The bedrooms have good quality and adequate storage facilities that are appropriate for short stay visits. 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 21 The manager talked about the home’s maintenance; decoration and development plan, and said that since the last inspection a plasma screen TV, sofa and two reclining chairs had been purchased and the lounge redecorated. The conservatory leads into a good size secluded garden designed to promote stimulation and to provide outdoor activities. The tour of the premises found to the home has a range of aids and equipment such as hoists and floor mats that may be used by all service users. Service users bring their own specific specialist equipment, such as wheelchairs into the home with them. Disposable protective clothing is readily available and used by staff when attending to personal care needs and when handling soiled linen, incontinence pads or clinical waste. Clinical waste and soiled pads are held separately and collected for disposal every Friday. Staff washed their hands regularly and the support worker who prepared the main meal wore a washable apron. Staff spoken with said they had attended training in the prevention and control of infection and were able to give examples of how infection and cross contamination could occur. For example serving high-risk cooked foods such as chicken that was not properly cooked. On the day the inspection, the home was clean, tidy and fresh. The laundry was well managed. To prevent risk of infection a sluice programme on the washing machine is used for any heavily soiled items. 151 Valley Road DS0000004221.V314737.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): 32,34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by sufficient numbers of experienced and trained staff to meet their needs, but are not always protected by robust recruitment procedures. EVIDENCE: The home provides sufficient numbers of staff to ensure service users needs, including social needs are met. Bookings are planned every three months and the staff rota is planned according to the number and needs of service users. The staff complement comprises of: the manager, care coordinator, administrator and 14 support workers. The home does not employ catering or domestic staff, as these tasks are included in the support workers’ role and responsibilities. All the staff employed are female. Examination of staff rotas showed there are always two support workers on duty and at night, there is one awake and one sleeping in. At weekends the staff numbers remain the same but the start and finish times differ. 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 23 It was clear through observations that the service users needs were being adequately met with this staffing level. Relatives who provided feedback felt service users needs were being met safely and appropriately. A training matrix is used to identify individual training needs including any updates. Staff receive training to help them meet service users needs appropriately and safely. Some examples are: challenging behaviours, health and safety, moving and handling, communication, disability and you and enteral feeding. To further enhance staff communication skills future training is to include ‘signing’. Two staff discussed the mandatory training they had undertaken which included, food hygiene, first aid, health and safety and fire safety. There is an active National Vocational Qualification (NVQ) programme in place, which includes new staff attending Learning Disability Award Framework, (LDAF). The manager confirmed that nine of the 14 support workers have completed an NVQ 2 or equivalent and therefore 64 of the staff team are suitably qualified. Staff training is arranged around service users needs, ensuring they are met appropriately. The home closes for seven days each year to provide staff training. The home has a low staff turnover and most of the staff have been in post for a number of years. The staff provide any additional cover needed for absent colleagues and agency staff are not used. The manager talked about the staffing arrangements and said there had been one new appointment since the last inspection. Examination of two staff personnel files including the most recent appointment showed that most of the pre-employment checks such as references, evidence of identification and medical clearance had been secured. However, the outcome of a Criminal Record Bureau (CRB) disclosure and checks against the Protection of Vulnerable Adults register (PoVA) in respect of a member of staff who began working at the home on 21st April 2006 was not received by the home until 27th July 2006. This shortfall has resulted in a requirement being issued to make sure new employees do not work with vulnerable adults until all the information necessary to determine fitness has been secured. 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed but quality assurance monitoring is not regarded or implemented as a core management tool. Relevant health and safety policies and procedures promote the health and safety of people who use the service. EVIDENCE: The manager has completed the Registered Manager’s Award (RMA), NVQ 4 in care and is an assessor for the Learning Disability Award Framework (LDAF). The manager is experienced and is currently developing her skills further by helping to manage a domiciliary care team operated by the organisation. 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 25 The staff spoke highly of the manager and care coordinator and said they felt well-supported and received clear direction and leadership. The manager and staff are very service user focused and ensure the home is run in the best interests and needs of the service users. This was observed throughout the inspection and has been reflected throughout this report. There is a quality assurance process implemented by the Leonard Cheshire Foundation on an annual basis, which includes seeking the views of service users or their carers. The manager talked about the quality assurance process confirming the questionnaires for this years quality review should be returned for audit by January 2007. The manager said the questionnaire was available in other languages and in audiocassette. The inspector read the questionnaire and found the format unsuitable for service users with complex communication needs and profound disabilities. Parents, carers, health and social care professionals and other stakeholders must be consulted and their views obtained and used to further develop the service. Other methods used to obtain feedback about the service include an evaluation questionnaire sent out after each short stay. The manager said the response was poor. Regular visits by the registered person or their representative to monitor the service were not being implemented as required by the Care Home Regulations 2001. This shortfall must be addressed so that we can be sure the service is being regularly monitored and the health, safety and welfare of service users protected. Fire safety in the home includes an individual evacuation procedure for each service and regular fire drills. We obtain information before inspections. The information includes confirmation that all necessary policies and procedures are in place and are upto-date. These are not inspected on the day but the information is used to help form a judgment as to whether the home has the correct policies to keep service users and staff safe. In this instance, policies and procedures were in place. These along with risk assessments are reviewed regularly and are updated where necessary, to ensure they are appropriate and reduce risks to staff and service users. 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA34 Regulation 19 Schedule 2 Requirement The Registered Person must not in future employ people to work with vulnerable adults until the outcome of a Protection of Vulnerable Adult (PoVA) check or Criminal Record Bureau (CRB) disclosure necessary to determine fitness is known. The Registered Person or delegated person must visit the home monthly and write a report upon the conduct of the care home. A copy of this report must be available for inspection. The Registered Person must develop and introduce a quality monitoring and assurance system, which ought to contribute to the annual development plan specified in standard 39 and take account of the views of parents, carers and other stakeholders. Timescale for action 31/10/06 2. YA39 26 31/12/06 24 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 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. Refer to Standard Good Practice Recommendations 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 151 Valley Road DS0000004221.V314737.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!