Inspection on 10/07/07 for 2 Seafarer`s Walk

This inspection was carried out on 10th July 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

2 Seafarer`s Walk 17/06/08

2 Seafarer`s Walk 15/06/06

2 Seafarer`s Walk 22/11/05

Similar services:

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

Pinta

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

CARE HOME ADULTS 18-65 2 Seafarer`s Walk Sandy Point Hayling Island Hampshire PO11 9TA Lead Inspector Laurie Stride Unannounced Inspection 10th July 2007 09:45 2 Seafarer`s Walk DS0000064967.V341317.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 2 Seafarer`s Walk DS0000064967.V341317.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. 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 2 Seafarer`s Walk Address Sandy Point Hayling Island Hampshire PO11 9TA 023 9246 8343 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.c-i-c.co.uk Community Integrated Care Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th June 2006 Brief Description of the Service: The home is situated in a quiet residential area to the southeast of Hayling Island and within easy reach of the beach. Local shops and amenities can be accessed, but to use a wider range of facilities travel is necessary to locations off the island such as Portsmouth, Southsea and Havant. The home is situated next to a similar registered home. The homes share the front car park. The home was purpose built with suitable adaptations and all of the facilities are provided on one level with the exception of the garden. This slopes away to the front and rear of the home making independent use difficult and restricting the amount of usable space. The home is suitable for people who have physical as well as learning disabilities. All of the service users have single rooms. They have use of the kitchen/diner, a lounge and a sensory room. The current fee is £1155.87 per week. This information was obtained at the time of the inspection visit. Members of the public may wish to obtain more up-to-date information from the care home. 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection visit, which lasted approximately eight hours, during which the inspector spoke with the home’s manager and staff on duty and met some of the people who use the service, whose needs are such that they were unable to contribute verbally to the inspection process. A telephone survey was conducted with relatives of two of the people who live in the home and a care manager. Samples of the homes records were seen and a tour of the premises was undertaken. The registered manager had also provided information about the service in the annual quality assurance assessment (AQAA). The findings of the previous inspection report of June 2006 were also reviewed as part of the evidence used for this inspection report. What the service does well: What has improved since the last inspection? Information for people interested in using the service has improved and continues to be developed to make it more user friendly. Care plans have been developed further to include individual goals and how these are being fulfilled. Systems for storing confidential information about people who use the service have improved. Improvements have been made to the premises to include more and better facilities for people who live there, including a new bathroom and summerhouse. 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 6 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. 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. A system is in place to ensure that prospective residents needs are assessed before they are admitted to the home. Information available to people who use the service and their supporters has been partially reviewed, although further work is required to ensure that it is as clear as possible and that it provides full details of the service provided. EVIDENCE: The current residents have lived at the home for a number of years, the most recent arriving in 2004. An admissions policy was seen in which it was made clear that no prospective resident would come to live at the home without having had their needs and wishes assessed. The Statement of Purpose and Service User Guide has been further developed since the last visit to the home. Parts of these are general information relating to the organisation, although other parts are more specific to the service. The statement now contains information about the home only being able to admit two people who are wheelchair users due to the layout of the home. The main body of the statement is in written form and as such is not accessible to people who use the service. However pictorial elements have been introduced to the guide and the manager said she had requested an audio version. The guide 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 9 does not contain the required details of the total fee payable and the manager said she would take this matter forward to a meeting with a senior manager of the organisation. Relatives of people who use the service confirmed that they had received information about the service and had the opportunity to visit the home prior to any decisions being made about admission. The manager had provided data about the home prior to the visit and this stated that all people who use the service have copies of the terms and conditions of residence. A sample of records seen during the visit confirmed that written agreements are in place, which have been signed by the relevant individuals’ representatives. 2 Seafarer`s Walk DS0000064967.V341317.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): 6, 7, 9 & 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Systems for care planning and risk assessment have been improved and this needs to continue to clearly meet individuals’ needs and wishes. Improvements have also been made to ensure that confidentiality is respected. EVIDENCE: The last two inspection reports identified that there was insufficient evidence of clear up to date care plans being followed through, and that service users would benefit from person centred planning. A sample of care plans and risk assessments was seen in relation to three people who use the service. These showed that a number of individual goals have now been identified and there are records of monitoring to ensure these are followed through. Some of the goals are currently the same for all residents, however there are others that are clearly individual. These plans have just started to be implemented and show a more person centred approach than was previously seen. As at the last two inspections, there was little evidence about how people who use the service are helped to make choices, although staff spoken with had a 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 11 good knowledge of individual’s likes and dislikes. The home’s current manager took up post after the previous inspection and has been experimenting with a variety of formats for person centred planning. Information contained within these multiple formats indicated if individuals are able to make choices but does not say how or show how plans reflect the person’s choices. More information is needed about how individuals’ communicate with staff in the home. For example the manager showed how one resident communicates using a book, however this was not recorded as part of the person’s care plan. There was evidence of care plans being reviewed and a new monthly review form being introduced at the time of the inspection will help staff to look at what has been achieved and how improvements can be made. All but one of the people who use the service had a review with the care manager responsible for their placement, in December 2006. Risk assessments had also been reviewed and following a previous requirement, action had been taken regarding the use of bedside rails. A written agreement with a health care professional was in place that this is in the individual’s best interests. The manager identified that a record showing how the use of bedrails is monitored needs to be part of the risk assessment and said she would put this in place. One of the strategies staff spoke about for managing another residents’ particular behaviour was also not in the person’s care plan or risk assessments. The manager said this would be done. (See Concerns, Complaints and Protection). Discussion took place over the telephone with the relatives of two residents, who felt that the service meets the needs of individuals in the home. One said that their relative in care lets people know what s/he wants and staff are good at interpreting individuals’ needs. Another said the manager and staff are willing to listen and learn, using relatives knowledge to build up a better picture of the individual resident and develop care plans. Systems for storing information about people who use the service have improved and information is held securely. The previous inspection identified that consideration should be given to ensure that confidentiality was maintained. The manager reported that residents are no longer present at staff meetings where issues about other residents are being discussed. The minutes of recent meetings provided further evidence of this. 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities to take part in appropriate activities continue to improve. The process by which staff communicate with residents’ to ensure activities reflect their needs and wishes could be made clearer. Family links and friendships are effectively maintained. Food provided is varied and nutritious. EVIDENCE: The previous inspection identified that there are three staff members on duty during the day and some residents have been identified as needing 2-1 support when out, which potentially limits the number of activities that individuals can do. Current staffing levels at the time of this visit were seen to meet the needs of residents, including recreational activities. One resident regularly attends a day service, which gives some additional scope for staff to support the remaining people who live in the home. The manager said she has looked into the possibility of other residents accessing day services or college but these have not been available. The sample records seen of the most recent 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 13 care manager reviews, showed that other residents had not been assessed as requiring specialist day service or college involvement. Staff said that another resident no longer requires 2:1 support for short outings such as walks, due to a change in medication. Comments from a relative confirmed that their relative in care goes out on most days. There is a programme of weekly activities, with alternatives if residents do not wish to follow the program. Records for July showed what activities individual residents had taken part in. For example, there had been a ‘Chinese evening’ themed food night to celebrate the Chinese year of the pig, drives, a DVD night and visit to the funfair. A ‘mobile farm’ has been booked to visit the home in September. Relatives confirmed that the home supports individuals to have holidays and the manager said there is a budget for this. As stated in the previous section, care plans identify individual goals and there are records of monitoring to ensure these are being followed through. A sample of goal plans was tracked to see what the outcomes were and the system was seen to be working to benefit the individuals concerned. For example, one person’s goals were to go swimming and out for a meal once a week, to access the community for personal shopping and to have breakfast at a local café once a week, and once a month to go to the dog track, a cinema or funfair. The records showed that all but the swimming had taken place in the previous week, which was due to staff sickness. The sample of records indicated that alternative dates or activities had been arranged to compensate for when this happened. A number of the staff are able to drive the homes vehicle, which is adapted to enable access for wheelchair users. Each resident pays a set amount as part of an agreement for use of the vehicle, which is signed on their behalf by a representative of CIC. The previous inspection identified that all pay the same although it appeared that the use of the vehicle had differed between individuals. The manager reported that this had applied to one individual who now uses the vehicle more often and that this matter had been discussed and agreed with the individuals’ representatives. Some daily routines promote individual choice, for example residents are supported to get up when they choose, and to eat when and where they want. People who use the service are able to make choices about use of rooms in the house. One person prefers to spend more time in the bedroom than elsewhere in the house. Staff spoke of monitoring this and of the signs and behaviours that show the resident’s preferences. Staff were observed to interact positively with residents. There are two guinea pigs as pets. A residents’ relative commented that staff are good at interpreting individuals’ needs. Further discussion identified that the home always supports residents to keep in touch with their relatives and keeps the relatives informed of important issues. Discussion with staff provided further evidence that friends and 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 14 families are welcomed and that their involvement in daily routines and activities is encouraged. One relative commented that they had been surprised how their son/daughter has developed in the home. Staff and relatives spoken with felt that the residents ate well and were able to make choices at mealtimes. A menu is provided but is not necessarily kept to. However records did show that a variety of foods are provided. Staff said that they were aware of what residents liked and disliked. Some pictorial menus are used in the home to increase opportunities for residents to make choices about food. 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care received by residents is based on their individual needs, but this is put at risk through a lack of clarity in recording needs. There is a medication procedure in place that protects people who use the service. EVIDENCE: Monthly key worker reports show how residents’ health care and support needs are monitored and what actions are taken. One entry referred to monitoring a residents’ IBS (irritable bowel syndrome). The manager said that a professional had examined the individual and that IBS had not been confirmed. The record was not therefore of a professional diagnosis but the opinion of the person completing the record. The manager stated that this matter had been previously discussed among the staff team. Residents’ health care records need to provide accurate information to ensure they are receiving proper support. As identified in previous sections of this report, more information is needed about how staff members communicate with individuals living in the home. 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 16 There are records showing that residents have regular access to the epilepsy clinic and had also been seen by a dietician when necessary. Care manager reviews held in December 2006 stated that no new needs had been identified and residents appeared settled. A care manager commented that the home does not contact them for advice, but that management ‘backup’ and support for staff providing care had improved. Also that staff had been observed to talk respectfully to residents, knock on bedroom doors and ask to come in. Relatives said they are kept updated regarding residents health care and that the staff are very caring. They also commented that outside agency staff are very rarely used, which ensures good continuity of care for residents. A number of people who use the service have limited vision. Since the last inspection, the manager and staff have had further training and guidance to support people with a visual impairment. Staff said this had been very useful to them in their work with residents. Specialist equipment is available in the home and staff are trained in its use. Medication was observed to be securely and appropriately stored in a new purpose built cabinet. Records checked of medicines administered tallied with stocks held. Records showed that staff had been trained in the safe handling of medicines, including specific training provided by the District Nurse. Guidance is provided for staff in how to proceed if a resident refuses to take medication. Since the last inspection the home had liaised with a healthcare consultant about disguising medications in food, and a written agreement that this is in the best interest of the individual concerned had been recorded. 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s complaints procedure has been made more user friendly and an open atmosphere in the home promotes good communication. There are policies and procedures to protect people who use the service, but staff interventions are not adequately recorded. EVIDENCE: A Complaints procedure is on display, which does not include timescales for responding but informs people who to complain to. The manager said she would put the timescales in. There is a pictorial version of the procedure in the Service User Guide and this is an improvement in the service. The manager said she had requested and is awaiting an audio version of the procedure, which will further benefit the people who live in the home. No complaints had been received by the home. Residents are consulted on a day-to-day basis and rely on staff observation and understanding of behaviours for their needs and wishes to be known. Discussion with resident’s relatives confirmed that they had received copies of the procedure and knew how to make a complaint if they needed to. Relatives also commented that they felt they had a good relationship with the manager and had no problems with approaching her to discuss any concerns. Records show that all but new staff have training in adult protection and the home has copies of the relevant procedures. Staff spoken with demonstrated an understanding of the procedure for reporting abuse. Staff said they received training in Non-Violent Crisis Intervention, which teaches techniques 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 18 for managing challenging behaviour. Staff training records confirmed this. Staff spoken with said there had not been any occasions when they had to apply these techniques. One of the strategies staff spoke about for managing the particular behaviour of one resident is to ask if the individual would like to go to their room. Staff explained that the bedroom door is left open and the individual can come out when s/he wants to. The manager said this was done on the advice of a health care professional and the community learning disability team had also been involved. This was not in the person’s care plan and needs clarifying and reviewing regularly. The individual’s bedroom door has an automatic closer in case of fire, which had been fitted because this person likes to have the door open when in the room. Money held on behalf of one service user was checked and this tallied with records. Money was seen to be held securely and records showed that balances are checked twice a day, at the end of each shift. 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27 & 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Improvements have been made to the environment but people who use the service would benefit further from additional bathroom/shower facilities and the garden needs to be made safe. EVIDENCE: People who live in the home benefit from the use of a sensory room and equipment is provided to meet their needs. The service has provided one individual with a pressure relief bed and another with a new air mattress and specialist chair. A new specialist bath and hoist is in place and toilet with adjustable handrails. The manager and staff commented that bathing facilities could be further improved by having an additional shower, as residents sometimes have to queue to use the bathroom. There are currently no plans for this to happen. Bedrooms seen had been recently redecorated and were personalised to suit the interests of the occupants. Two bedroom doors are fitted with automatic 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 20 closers in case of fire and an order had been placed to fit similar equipment to the others. The lighting in the kitchen has been improved and a number of other improvements were noted. A summerhouse has been equipped with electricity, a sofa and television, providing additional space and facilities for people who use the service. The manager has developed an area to the front of the house, which now provides a lawn with seating and flower borders. The garden to the rear is on a steep slope. There is ramped access from the lounge to a patio, which is in need of repair. Sections of the patio brickwork are rising up, or slipping below the edge of the ramp, creating a trip hazard. This was discussed with the manager who said that it had been reported but that a decision had not yet been reached about it being repaired. One resident was previously able to access the patio independently but this was currently considered unsafe. A requirement has been made that the providers ensure action is taken to improve the area for residents. The laundry facilities are appropriately sited and are suitable to meet needs. New cupboards have been fitted in this area and there are new washing and drying machines. Paper towels and liquid soap are provided in the bathroom. Aprons and gloves were observed to be available to and worn by staff. Information regarding the control of hazardous substances was in place. 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are provided with training and support to help them to meet peoples’ needs effectively. Residents are protected by a robust recruitment procedure, however the records to show this has always been the case are incomplete. EVIDENCE: Staff members on duty were spoken with and a sample of three staff files was seen. Staff members demonstrated knowledge of residents’ individual needs and agreed ways of working with them. The manager reported that out of 15 care staff, 7 permanent and 2 bank staff are qualified to NVQ level 2 or above. The home’s records provided evidence that the home is operating a thorough recruitment process in order to protect people who use the service. The 3 staff members’ files contained evidence of Protection of Vulnerable Adults (POVA) and Criminal Records Bureau (CRB) checks, 2 written references, completed application forms with employment histories. These also included information about staff induction, supervision and training. 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 22 Not all records relating to staff are currently available in the home. The manager explained that when ownership of the home changed, a number of staff already working in the home had transferred to the new provider. It was not clear what had happened to the records showing that these staff members’ had been through a thorough recruitment process. E-mails were seen showing that the manager has been in contact with the previous service providers and with the Commission for Social Care Inspection customer helpdesk in order to try to resolve this matter. It is a requirement that records are held in the home that demonstrate that all staff who work there are fit to do so. The manager stated she will continue to chase up the necessary information. New staff have a probationary period and written reports were seen monitoring their progress and development at 6 week and 3 month intervals. There is a structured induction, which includes an introduction to individuals living in the home, their care plans and assessments. Records also showed that staff receive regular formal supervision with the manager. The sample of staff records showed that training is provided to meet the needs of people using the service and to comply with legislation. Training includes moving and handling, emergency aid, fire safety, infection control, food hygiene, medication, principles of care, safeguarding adults, non-violent crisis intervention and working with people with visual impairment. The manager and staff said that there are plans to provide training in communication. Staff members felt that they were part of a good team. The relatives of two residents commented that staff are ‘all very caring’ and ‘dedicated’. 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The current day-to-day management of the home benefits the people who live there and there are plans to register the manager. However further work on quality assurance systems is needed to ensure that the service is meeting the wishes and needs of residents. The home generally promotes safe working practices although further work is needed to ensure residents are protected. EVIDENCE: There have been changes in the management arrangements for the home since the new providers took over, but this is now stabilising. The current manager has been in post since October 2006 and has also worked in the home in a caring role. The manager stated she is chasing up references for an application to register with the Commission for Social Care Inspection and starts working toward the NVQ level 4 Registered Manager Award in September 2007. The manager has also attended a number of relevant 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 24 training courses to keep her skills updated. Relatives commented that the manager is open, efficient and good at communicating with them and staff confirmed this view. There have been a number of improvements to the service identified in this report. There are also matters that require the attention of the homes’ management to enhance the quality of service and ensure the continued safety and welfare of the people who live there. This includes further work on care plans and risk assessments, staff records and maintaining a safe environment. Feedback from residents is mostly non-verbal and obtained through staff and relatives. There is currently not a formal method, for example a survey, of obtaining the views of relatives and other stakeholders, such as health and social care professionals. This was discussed with the manager who said she would take this forward. The manager meets with other managers in the organisation to share information, develop and improve the quality of services. The manager said that one way the service was developing was through the planned communication training for staff. Staff meetings are held within the home that include discussion of issues relating to resident’s quality of life. A senior manager undertakes monthly monitoring visits to the home and reports of these were seen. Data provided by the manager showed that the homes’ special equipment and domestic appliances are tested and serviced regularly. Staff receive training in health and safety matters, including fire safety last held in June for all staff. There are clear and detailed fire procedures for day and night staff and the manager stated that he fire officer had approved these. This is an improvement since the last inspection. Action was being taken regarding a recommendation about fire door closers and the homes fire risk assessment had been reviewed. 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 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 2 2 3 X 2 X 2 X X 2 X 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 26 Yes 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 YA6 15 Requirement Care plans must clearly detail how individuals’ needs in respect of their health and welfare are to be met. Including how risks are monitored and the interventions used by staff to manage behaviour that challenges the service. This is a partially repeated requirement from 15/06/06 and 12/9/05. Timescale of 31/08/06 not met. 2. YA24 23 (2) (b) The patio area to the rear of the property must be repaired and made safe for residents to use. 01/10/07 Timescale for action 01/10/07 3. YA34 17(2) Records must be kept of all 01/10/07 persons employed at the home, including all information specified in schedule 4 of the regulations. This information must be available for inspection. A system for seeking the views of people who use the service and their representatives must be in place, to monitor the outcomes of and inform service DS0000064967.V341317.R01.S.doc 4. YA39 24 (3) 01/10/07 2 Seafarer`s Walk Version 5.2 Page 27 provision. This is a repeat requirement of 15/06/06 and 12/9/05. Timescale of 30/09/06 not met. 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 YA27 Good Practice Recommendations Consideration should be given as to the possibility of installing an additional shower facility for people living in the home. 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 2 Seafarer`s Walk DS0000064967.V341317.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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