Inspection on 31/07/08 for 22-24 St Hughs Avenue

This inspection was carried out on 31st July 2008.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

22-24 St Hughs Avenue 04/08/06

22-24 St Hughs Avenue 02/03/06

22-24 St Hughs Avenue 11/12/05

22-24 St Hughs Avenue 01/02/05

22-24 St Hughs Avenue 29/07/04

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Dalewood Respite Care

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REACH Upton Court Road

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Treloar College

Kestrel House, St Anne`s Opportunity Centre,

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Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 22-24 St Hughs Avenue Micklefield High Wycombe Buckinghamshire HP13 7JD Lead Inspector Mike Murphy Unannounced Inspection 31st July 2008 09:30 22-24 St Hughs Avenue DS0000023046.V367716.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 22-24 St Hughs Avenue DS0000023046.V367716.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. 22-24 St Hughs Avenue DS0000023046.V367716.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 22-24 St Hughs Avenue Address Micklefield High Wycombe Buckinghamshire HP13 7JD 01494 444507 01494 444507 manager.sthughs@fremantletrust.org www.fremantletrust.org The Fremantle Trust 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 Pamela Wheeler Care Home 6 Category(ies) of Learning disability (0) registration, with number of places 22-24 St Hughs Avenue DS0000023046.V367716.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD). The maximum number of service users to be accommodated is 6. Date of last inspection 4th August 2006 Brief Description of the Service: 22-24 St Hugh’s Avenue is located in a residential area, Micklefield, east of High Wycombe town centre. It is registered to provide accommodation for up to six adults with learning disabilities. The home is close to local shops and transport into nearby towns and is managed by The Fremantle Trust. All bedrooms are single and the home has been decorated and arranged to reflect a family environment. The average weekly fee at the time of this inspection was £599.62 22-24 St Hughs Avenue DS0000023046.V367716.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2. This means the people who use this service experience good outcomes. This unannounced inspection was carried out over the course of one day in July 2008. It was a key inspection which focused on the key standards in Care Homes for Adults (18-65). The inspection included a visit to the service, conversations with three people living in the home, conversations with the manager and staff, a tour of the home and garden, and examination of records (including care plans and personnel files). The inspection did not include a survey of residents because they had only been living in the home for around six weeks. The Annual Quality Assurance Assessment (AQAA) for the service which had been completed by the previous manager was referred to for background information but was not directly relevant to this inspection because the staff and residents living there at that time had moved on to a new Fremantle Trust development elsewhere in High Wycombe. The staff and residents currently living there had transferred to the home from another Fremantle Trust home in High Wycombe which had closed for redevelopment. The changes were part of a larger Fremantle Trust and Buckinghamshire County Council strategy to improve services for people with a learning disability in Buckinghamshire. The home is located in a residential area within reach of local shops and services and within walking distance of bus services to High Wycombe. The three people resident at the time of this inspection appeared to be settling in well. One said that it was “a nice home” and better than the one she had moved from. It provides domestic style accommodation for up to six people. Staff are available 24 hours a day to provide support to residents. The home has good arrangements in place for ensuring that it can meet the needs of people living there. It liaises closely with local health and social services organisations. Its assessment and care planning procedures are comprehensive but its care plans are complex for this type of service and are not easily accessible to residents. It should develop a person centred plan (PCP) format and should be supported in doing so by the Fremantle Trust which has experience of PCPs in some of its services. People living in the home lead active lives and all those resident on this inspection had a diary which over the course of the week included participation in a range of social, educational and recreational activities. Staff provided good support and in turn are well supported by the Fremantle Trust through its arrangements for training and development and management support and supervision. 22-24 St Hughs Avenue DS0000023046.V367716.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Develop a PCP care plan format. The present system, while comprehensive and thorough, is not readily understandable to people living in the home and does facilitate their involvement in developing their own care plans. Include evidence on the record that any gaps in the employment history of prospective staff have been appropriately explored prior to appointment. 22-24 St Hughs Avenue DS0000023046.V367716.R01.S.doc Version 5.2 Page 7 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. 22-24 St Hughs Avenue DS0000023046.V367716.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 22-24 St Hughs Avenue DS0000023046.V367716.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, 3, and 4 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 their needs will be carefully assessed before admission to ensure the home can meet those needs. EVIDENCE: The home had three people living there at the time of this inspection. There were three vacancies. The former residents of St Hugh’s had moved on to new accommodation, also in High Wycombe, earlier in the year. The three current residents had moved from another Fremantle service in High Wycombe, ‘Cressex Road’. Some of the staff who had provided support at ‘Cressex Road’ had moved on with the residents. The changes are part of a larger joint Buckinghamshire County Council and Fremantle Trust strategy to improve the quality of services for people with a learning disability in Buckinghamshire. There is a clear process in place for assessing the needs of prospective residents. Referrals are made by local authority care managers. These follow an assessment of the person’s needs by a care manager. The manager of the home receives the referral and together with staff considers whether the home is likely to be able to meet the person’s needs. 22-24 St Hughs Avenue DS0000023046.V367716.R01.S.doc Version 5.2 Page 10 Where the referral is progressed arrangements are made for a meeting with the person and their family. The meeting provides an opportunity to acquire further information on the person’s needs and for the person, the prospective resident, to ask any questions they might have about the home at that point. Arrangements are made for a visit to the home to view its facilities and meet the people currently living there and staff. Where the referral continues to move forward arrangements are made for an overnight and weekend stay and then a ‘trial’ admission of around three months. The information available to the home at this early stage may include the Buckinghamshire Client Assessment Report, personal details, key contacts, current service used by the person, a carer or family view of the situation, a assessment report and assessment summary. The home’s admission assessment includes: the reason for the referral, practical support required, health care needs, environment and mobility, cultural needs and personal beliefs, compatibility with others already living in the home, and current day activities. A form which rates the person’s needs includes: risk, suitability to home resources, compatibility with others already living in the home, financial aspects, and, the wishes of the person The process takes place at a pace which suits the person. All parties; the prospective resident and their family, the referring care manager, and staff and current residents have an opportunity to acquire more information at each contact. This enables them to get to know each other and to decide if the home can meet their needs. On the day of the inspection visit a prospective resident visited the home with a social worker. The visit had been arranged in advance. Refreshments were offered and everyone attended a meeting. The person then had a tour of the home and any questions were answered. The overall tone was relaxed and informal and appropriate to the needs of all concerned. The person expressed satisfaction with the visit and an interest in moving in to the home. Further contacts between all parties would take place over the following days and weeks. 22-24 St Hughs Avenue DS0000023046.V367716.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, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comprehensive care plan is in place for each resident. Care plans include details of resident’s preferences and a range of risk assessments. Care plans aim to ensure that residents needs are met, that independence is supported, risk is minimised, and that care is provided in accordance with the person’s wishes. However, care plans are not currently in a form which facilitates the participation of the person in their own care. EVIDENCE: There is a care plan in place for each person living in the home. Each person also has a key worker. 22-24 St Hughs Avenue DS0000023046.V367716.R01.S.doc Version 5.2 Page 12 Care plans are comprehensive but complex. At the time of this inspection the home had not developed person centred plans (‘PCPs’) but acknowledged the need to do so. This would be highly desirable for two reasons. Firstly, the PCP approach fits very well with this kind of service. Secondly, and more important, the PCP approach is more accessible to residents and facilitates their involvement in developing their own plans. Those living in the home on the day of this inspection visit would benefit from that. The Fremantle Trust should be able to provide guidance and support to the home in developing a PCP approach. The care plans of all three people resident on the day of the visit were examined. They are comprehensive. They include a photograph of the person, the assessment information listed in the previous section, a ‘pen picture’, essential information, a ‘personal lifestyle summary’, a detailed assessment of needs, and correspondence with local NHS and other statutory services. Care plans include assessment and support required in: mobility, communication skills, washing and bathing, continence, personal grooming, food and drink, family contacts, friends, spiritual beliefs, leisure and recreation, education and learning, health, dietery needs, monthly weights, risk assessments, and last wishes. People living in the home are supported in making decisions by their key worker and other staff. Their seemed to be a good relationship between staff and residents which supports that process. This is a small home and at the time of this inspection the residents and staff had only been there for less than two months or so. Each person living there has a ‘home day’ once a week. On that day they do some of their own domestic tasks (such as cleaning their room or doing their laundry), are supported in pursuing their own particular interests, or go shopping or have lunch out. There are fortnightly house meetings between staff and residents. Risk assessments cover a range of activities including: walks out in the local area, going out to buy fast food, using kitchen equipment, using the shower, travelling in a car or on public transport, and managing money. 22-24 St Hughs Avenue DS0000023046.V367716.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): 11, 12, 13, 14, 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. People living in the home lead a varied lifestyle according to their individual interests, abilities and wishes. This ensures that people experience a range of social, leisure and other activities and are involved with the local community. EVIDENCE: The home endeavours to support people living there to develop their skills. The three people resident at the time of this inspection led active lives and all were clearly able to articulate their views and wishes. They were settling in well and one said “It’s nice here. The staff are nice. It’s better than Cressex Road (former home, now closed for redevelopment)”. Residents are supported in maintaining relationships with families and friends. The amount of contact with families varied depending upon individual circumstances. 22-24 St Hughs Avenue DS0000023046.V367716.R01.S.doc Version 5.2 Page 14 Residents attended Life Skills courses run by Amersham and Wycombe College at its Flackwell Heath and Amersham campus. Residents make use of the amenities of the locality and the wider High Wycombe area. These include local shops and post office, a new cinema in the town centre, a bowling complex and exploring pubs. They also go to WASAD a sports club which is run on Sunday evenings and includes netball and swimming and which generally encourages activity. One person supports a local church in its voluntary activities including supporting others on activities, helping to distribute furniture to people in need, running barbeques, and helping with a soup kitchen in London. Others enjoyed shopping, gardening, computing, music, visits to family and going on holiday with them, art, writing, and meals out. One person had recently been on a four day holiday on the south coast and said that she had “Enjoyed it”. People living in the home lead busy and lives and on the day of inspection (a typical day) were out of the house until mid-afternoon. People’s daily routines are flexible but to a large extent the day is structured by a person’s commitment to daytime activities. Residents and staff plan meals together on Sunday evenings. Staff and residents prepare meals together – staff are trained in food hygiene by the Fremantle Trust and residents have received training in college. Menus are on display in the kitchen. Each resident prepares his or her own packed lunch. External advice is sought in relation to any special dietary requirements. 22-24 St Hughs Avenue DS0000023046.V367716.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff support residents as required. Arrangements for liaising with health and other support services in the community are good. Arrangements for the control and administration of medicines are satisfactory. Together, these aim to ensure that the healthcare needs of people living in the home are met. EVIDENCE: Staff provide support and guidance to residents as required. Personal care is provided in bedrooms or one of the shower rooms where required. The home is not suitable for a person requiring significant support with mobility. The people living in the home are physically independent. All residents are registered with a local GP practice. District and specialist diabetic nurses provide support and advice as required. The services of a psychologist or psychiatrist are accessed through the Community Learning Disability Team (CLDT). 22-24 St Hughs Avenue DS0000023046.V367716.R01.S.doc Version 5.2 Page 16 Other health professionals are accessed either directly (such as opticians or NHS dentists) or through the health centre (e.g. specialist nurses or other professionals). Medicines are prescribed by the person’s GP and are dispensed by Boots Chemists in High Wycombe. The home is required to conform to the Fremantle Trust policy and procedures with regard to medicines. Staff training is provided through the Trust supplemented by training from Boots Chemists. A reference textbook on medicines was the 2000 edition. There is a more recent edition of that book (published in the autumn of 2007) and a copy should be obtained by the manager. Arrangements for the storage of medicines are satisfactory. All bedrooms have a lockable medicines cabinet fixed to the wall. There is a refrigerator for the storage of medicines requiring cool storage (such as Insulin). Only one person was on medication at the time of this inspection and examination of the arrangements for that person showed satisfactory practice. One person on insulin had been trained to do relevant blood checks and administer the injections. The Trust policy on end of life care was under review. 22-24 St Hughs Avenue DS0000023046.V367716.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good framework of policy, reporting arrangements and staff training with regard to complaints and safeguarding adults. These aim to protect people in the home from abuse and to ensure that complaints are properly investigated. EVIDENCE: The complaints process is published for residents and visitors as ‘Fremantle Feedback’. This also allows for compliments to be communicated to the organisation. It is presented in picture and concise easy read format. The home had not received any complaints since people moved in six weeks or so earlier. CSCI have not received any complaints about this service in the year to date. All staff have received training in safeguarding vulnerable adults (SOVA) and the manager is a SOVA trainer. There have been no SOVA events since the last inspection. An advocacy worker from Talkback Advocacy visits monthly. These visits had increased in frequency in recent months to provide additional support to residents over the transition from the former home to St Hugh’s. The home had a copy of the Fremantle Trust policy on safeguarding vulnerable adults. However, its copy of the Buckinghamshire joint agency policy did not appear to be the current one (published in March 2007) and it should obtain a 22-24 St Hughs Avenue DS0000023046.V367716.R01.S.doc Version 5.2 Page 18 copy from the relevant office in the local authority. It would also be advisable to obtain copies of the Buckinghamshire County Council leaflet on reporting abuse. The staff training programme includes training on responding to challenging behaviour – ‘Non-Aggressive Physical and Psychological Intervention’. The home supports residents in managing their money. Procedures are subject to the polices of the Fremantle Trust. The extent of involvement varies from person to person. For all residents an external person acts as appointee, either a member of their family or the local authority. Arrangements are in place for residents to have a bank account and savings book where required. The home deals with small amounts of cash. Arrangements are in place for secure storage. All transactions are recorded and receipts of expenditure retained. 22-24 St Hughs Avenue DS0000023046.V367716.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe, comfortable, clean, and homely environment for people living there. EVIDENCE: The home consists of two semi-detached houses adapted to form one home. Its external appearance is very similar to other houses in the area. There is a bus stop within a short walking distance with regular buses to High Wycombe town centre and other areas. The nearest local shop is in a garage a short walk away. The gardens to the rear are sufficient in size for the present number of residents and staff. One garden is mainly lawn. The other has a number of seating areas and provides a comfortable area for service users to relax in or hold small functions. 22-24 St Hughs Avenue DS0000023046.V367716.R01.S.doc Version 5.2 Page 20 The interior of the home is domestic in size and appearance. Rooms vary in size and four are less than 10.0 sq. m. All bedrooms are single. There is no ensuite accommodation. There are two showers and WCs. The home is not suitable for a person in a wheelchair or who requires assistance with mobility. The laundry is suitable for the needs of current residents. It is a very pleasant home which is bright and well decorated. All areas were clean and odour free. The home is comfortably furnished and residents have chosen the colour schemes for their own rooms. Bedrooms have a television point but not a telephone point. Although the residents and staff were still getting the house to their liking it had a comfortable ‘lived in’ feel. The present group of residents and staff had been in the home for a relatively short period of time – less than two months – at the time of this inspection visit and they were still getting the house together to suit their needs. Empty rooms were used for temporary storage, some minor adjustments to the environment installed for previous residents had been removed, and further redecoration was being planned. All areas of the home were clean, tidy and odour free. 22-24 St Hughs Avenue DS0000023046.V367716.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, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels, procedures for the recruitment of new staff, and for staff training, development and support are generally good. These aim to ensure that there are sufficient numbers of appropriately trained and supervised staff to meet the needs of people living in the home. However, an apparent insufficient rigour in the exploration of gaps in the employment history of applicants for staff positions potentially exposes people in the home to risk. EVIDENCE: The staff and residents had transferred from another Fremantle Trust home in High Wycombe which has now closed. Other staff in the former home had moved with other residents to new supported living accommodation in High Wycombe. Many of these staff were experienced and qualified to NVQ level 2 and above. An inevitable consequence of the change was a reduction in the proportion of such staff in both services. The manager expected this to be a 22-24 St Hughs Avenue DS0000023046.V367716.R01.S.doc Version 5.2 Page 22 temporary matter. The manager said that the Fremantle Trust has an excellent internal NVQ training programme and that she expected the proportion of staff qualified to NVQ and above to meet, and probably exceed, the minimum standard of 50 over the next year or so. As stated elsewhere in this report the relationship between staff and residents seemed very good. Staff were supportive to residents and residents were positive in their comments about the staff. Both staff and residents seen during the visit indicated that the move to St Hugh’s had gone well. For its current level of activity the staffing levels were two staff in the morning, two in the afternoon and evening, and one waking and one sleep-in at night. These figures will be reviewed in line with the number and needs of future residents. The home had two staff vacancies which were being covered by Fremantle Trust relief staff at the time of this inspection. The home is supported in the appointment of new staff by administrative staff based at the Trust’s head office in Aylesbury. Enquiries are dealt with by the manager, applications are dealt with by head office, and candidates are interviewed by two managers. Applicants’ complete an application form, are required to provide two references, have occupational health clearance, and provide an Enhanced CRB certificate. This process is satisfactory but examination of one file highlighted some weaknesses in the application of the process in all cases. The examination raised questions about continuity of employment, reasons for leaving previous episodes of employment in care, and the status of referees. While there may be good reasons for gaps in employment – extended time out to raise children for example – personnel files should include evidence that these have been explored at interview. For the reasons given above the proportion of staff holding NVQ 2 or above was below the 50 level at the time of this inspection. The manager was confident that this will improve over the next 12 to 18 months. The Fremantle Trust provides an excellent staff induction and training programme. However, the position with regard to the distribution of the General Social Care Council (GSCC) Codes of Practice was unclear and it would advisable to obtain copies (free) from the GSCC for staff reference. Staff supervision is well established in the Trust and evidence of its implementation in this home was seen during this inspection. 22-24 St Hughs Avenue DS0000023046.V367716.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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This is a well managed home where a positive approach to the quality of the service is providing good care outcomes for residents. Arrangements for health and safety are thorough and aim to maintain a safe environment for residents, staff and visitors. EVIDENCE: The manager was formerly the manager of Cressex Road, the service referred to earlier in this report which closed, and from which the residents now living in this home and the staff transferred. The manager is therefore, experienced in residential services for older people and for people with a learning disability, 22-24 St Hughs Avenue DS0000023046.V367716.R01.S.doc Version 5.2 Page 24 and in managing a residential for people with a learning disability. The manager has a foundation qualification in managing a care service, is an NVQ assessor, and has recently completed a Buckinghamshire County Council course on ‘Management in Care’. The manager said that she had started the process of applying for registration with CSCI for this home. The Fremantle Trust holds a number of systematic quality assurance activities. Given recent changes it was to early to assess the application of these at the time of this inspection. The Trust carries out an internal annual audit of its services. The organisation is accredited with Investors in People and ISO 9001 registered, each of which requires maintenance of quality assurance processes. Fremantle Trust managers carry out Regular 26 visits. The report for June 2007 was examined. Homes are required to hold an annual meeting with families and relatives. Given the closure of their former home and transfer to St Hugh’s meetings had been held earlier in the year with the families of residents. The manager is required to submit a monthly report on the service to senior managers. The home is subject to the health and safety policies and procedures of the Fremantle Trust. Staff attend training at basic and update level in moving and handling, fire safety, first aid, food hygiene, and infection control. As stated earlier in this report risk assessments relating to a range of activities involving individual residents were noted in care plans. The manager said that a fire safety risk assessment was being carried out at the time of the inspection visit. The home has a fire evacuation plan. Fire escape routes are checked daily. Fire training for staff had still to be arranged. A fire drill was carried out in July 2008. Fire points are checked weekly. Fire safety equipment and emergency lighting were checked in July 2008. Gas appliances were checked in July 2008. Systems are in place for recording accidents. One notification under Regulation 37 had been made to CSCI involving a resident scalding themselves in the kitchen. No serious injury was sustained. 22-24 St Hughs Avenue DS0000023046.V367716.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 X 2 3 3 3 4 3 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 2 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 4 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 x 22-24 St Hughs Avenue DS0000023046.V367716.R01.S.doc Version 5.2 Page 26 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 Requirement The registered persons are required to ensure that staff files include evidence that any gaps in the employment history of applicants have been explored prior to appointment. Timescale for action 31/08/08 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 YA6 Good Practice Recommendations It is recommended that the manager develop a format for care planning which is appropriate to the needs of people in this service and facilities their involvement in the process It is recommended that the manager obtain a copy of the current edition of the textbook on medicines for staff and resident reference. It is recommended that the manager obtain a copy of the current Buckinghamshire Joint Agency Policy on Safeguarding Adults. It is recommended that the manager ensure that all staff are provided with a copy of the GSCC Codes of Practice. It is recommended that the manager and the line manager assess what additional training and development, if any, is DS0000023046.V367716.R01.S.doc Version 5.2 Page 27 2 3 4 5 YA20 YA23 YA34 YA37 22-24 St Hughs Avenue required to fully meet the NMS management standard 37.2 22-24 St Hughs Avenue DS0000023046.V367716.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 22-24 St Hughs Avenue DS0000023046.V367716.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. 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