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Inspection on 09/01/07 for 24 Baveney Road

Also see our care home review for 24 Baveney Road for more information

This inspection was carried out on 9th January 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Detailed information about the home is provided for service users and is reviewed regularly which helps them and their families to make the right decisions about their care. The records and documents at the home are maintained to a high standard, and kept safely, which ensures a well-organised service. The care that is provided at the home revolves around the service users who live there, and their complex needs are understood and met in an appropriate way. The families of service users, or their representative are also supported and their involvement with the home is encouraged. The individuality of each service user is recognised, and the commitment of staff to supporting and enabling them to achieve as much as they are able is commendable. The activity programme enables each service user to do the things they enjoy and to make choices about their daily lives. A high standard of personal and health care is provided for each person living at the home, and the staff work well with other professionals and agencies with obvious benefit to service users. The Organisation follows good recruitment and selection procedures, and is clear about the support, training and development for the staff it employs. Staff confirmed that they have good training opportunities. The quality of the service provided at the home is checked to make sure that the home achieves what it says it will for service users, and to enable service users to say how they would like the service to develop. The building and equipment is well maintained and the house is nicely decorated, and is also comfortable, safe and clean.

What has improved since the last inspection?

There is an ongoing commitment from everyone involved at the home to maintain and develop the service. The care planning procedures have been reviewed regularly and adapted to suit the individual needs of service users. The opportunities for service users to do the things they enjoy have been increased, and the activities in which they are involved are now more varied. A review of the arrangements for purchasing and preparing food has given service users more choice about their meals and mealtimes. Medication procedures have been reviewed, further training given to staff, and additional information has also been provided which helps to ensure the safety of service users. Reviews of the medication prescribed for service users are undertaken regularly. Staffing levels have improved and the team is more settled, with benefit to both service users and staff. The new key worker system ensures that service users are given appropriate support at all times. Training has been provided for staff on death and bereavement and the protection of vulnerable adults from abuse. Arrangements have also been made with the Speech and Language Therapist for communication training to be given to staff. The manager has applied for registration, and continues to develop her skills.

What the care home could do better:

The planned redecoration of the lounge should be expedited to rectify the damage done by the water leak, and improve the appearance of the area for service users and visitors to the home. Training for staff on implementing Health Action plans for service users should be organised, to enable these records to be maintained more effectively. The need for reliable contractors to be available in the event of an emergency, is necessary to ensure the safety of service users. The outstanding information in respect of the managers application for registration should be obtained without further delay.

CARE HOME ADULTS 18-65 Baveney Road, 24 24 Baveney Road Worcester Worcestershire WR2 6DS Lead Inspector R McGorman Unannounced Inspection 9 January 2007 2:00pm th Baveney Road, 24 DS0000018627.V317860.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 Baveney Road, 24 DS0000018627.V317860.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. Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Baveney Road, 24 Address 24 Baveney Road Worcester Worcestershire WR2 6DS 01905 420706 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.dimensions-uk.org Dimensions (UK) Ltd Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: The Home is primarily for people with a learning disability who are under 65 years of age. The Home may also accommodate people with an additional physical disability and those who are over 65 years of age. Date of last inspection 9th January 2006 Brief Description of the Service: 24, Baveney Road is registered to provide residential care for up to 4 adults who experience a learning disability. The premises is a large, detached house situated in a pleasant residential area, approximately 2 miles from the City of Worcester, with easy access to public transport and a range of amenities and facilities. The home is owned and run by Dimensions (UK) Ltd., and is part of The New Dimensions Group, which, as the parent Company, provides strategic direction and a range of functional support services. The range of fees varies between £1,100 & £1,250 per week. The stated purpose of the organisation is, to work with people with learning difficulties, supporting them to make choices and to exercise control over their lives, and the main aim of the home is, to deliver a person-centred response to the needs and aspirations of the people we support. Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this routine key inspection, was to monitor the care provided at the home, to assess how well the service meets the needs of the people who live there, in relation to the stated aims and objectives, and to follow up previous requirements and recommendations. The visit was unannounced and took approximately 3 hours, when some time was spent with service users, mostly observing their interactions with the people who support them, as they are not easily able to communicate their opinions verbally. During conversations with staff, comments were made about what it is like to work for the organisation and also in the home with service users, at 24 Baveney Road. The care records of service users were seen, and discussion about the content held with the care manager, Mrs Julie Bedford, who was on duty during the inspection. The care plan of one service user was inspected in detail for case tracking purposes. A tour of the building was undertaken and the records kept in respect of the maintenance of equipment, and safe working practices were also seen, including the fire log book and the accident book. Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 6 What the service does well: Detailed information about the home is provided for service users and is reviewed regularly which helps them and their families to make the right decisions about their care. The records and documents at the home are maintained to a high standard, and kept safely, which ensures a well-organised service. The care that is provided at the home revolves around the service users who live there, and their complex needs are understood and met in an appropriate way. The families of service users, or their representative are also supported and their involvement with the home is encouraged. The individuality of each service user is recognised, and the commitment of staff to supporting and enabling them to achieve as much as they are able is commendable. The activity programme enables each service user to do the things they enjoy and to make choices about their daily lives. A high standard of personal and health care is provided for each person living at the home, and the staff work well with other professionals and agencies with obvious benefit to service users. The Organisation follows good recruitment and selection procedures, and is clear about the support, training and development for the staff it employs. Staff confirmed that they have good training opportunities. The quality of the service provided at the home is checked to make sure that the home achieves what it says it will for service users, and to enable service users to say how they would like the service to develop. The building and equipment is well maintained and the house is nicely decorated, and is also comfortable, safe and clean. Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: The planned redecoration of the lounge should be expedited to rectify the damage done by the water leak, and improve the appearance of the area for service users and visitors to the home. Training for staff on implementing Health Action plans for service users should be organised, to enable these records to be maintained more effectively. The need for reliable contractors to be available in the event of an emergency, is necessary to ensure the safety of service users. The outstanding information in respect of the managers application for registration should be obtained without further delay. Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 8 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. Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 4 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The information provided for prospective service users helps them to make decisions about their future care needs. The assessment process is detailed and thorough to ensure that the appropriate level of care can be provided. Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 11 EVIDENCE: A Statement of Purpose has been produced, and together with the Service Users Guide, which has lots of photographs, these documents provide detailed information about the facilities and services available at the home for residents and their families, who are then able to make the right decision about their future care needs. This information is currently being reviewed, to ensure that it is accurate. The information recorded about individual service users is kept by them, unless they have made other arrangements with staff. Their personal information is also reviewed regularly, to ensure that it covers all aspects of the care that is being provided. The documentation can be produced in an appropriate format if needed. There have been no recent admissions to the home, although the process was discussed with the manager, who confirmed that appropriate procedures are in place, and would include a detailed assessment by staff from the home, and also a Community Care Assessment by a social worker. Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service users plan of care is based on the initial assessment, which clearly identifies their assessed needs, and how these will be met. The key-worker system ensures that service users living at the home are supported in making choices in all areas of their lives. Service users are helped to take part safely in the various activities of daily living and to enjoy new opportunities. Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 13 EVIDENCE: An individual plan of care is produced for each service user, which is based on the initial assessment undertaken at the time the service user is admitted to the home. There was evidence in the care plans, of effective person centred care being delivered, and the positive interactions observed between staff and service users were pleasing to observe. The Essential Lifestyle Plan of one service user was inspected and was very detailed. A clear profile of the resident was given, and included their needs and wishes, their likes and dislikes, ‘the places I like to go, what makes me happy and what is important to me’, and ‘how I like to be supported with my personal care’. The daily routines about getting up in the morning and going to bed at night were also recorded in detail, and lots of photographs were included. Information about all the contacts and relationships made by the service user, and about how to communicate with them was also available. The Acting manager advised that a training day with the Speech and Language Therapist has been arranged for later this week, and further development of the various methods of communication with individual service users will then be implemented. The service users living at the home are not all able to communicate verbally, although everyone can make themselves understood in different ways. Staff are able to identify the individual wishes and needs of each service user, by interpreting their reactions to every situation. The service users made the inspector very welcome on arrival at the home. The service user who answered the door bell, shook my hand and invited me in, and another resident took me upstairs to see her bedroom, in which she kept her many treasured possessions. One service user made me a cup of tea, with the assistance of a member of staff, while another resident frequently checked to see if I was OK, between sitting down to have a little rest themselves, after a busy morning out shopping. The development of a more person centred approach towards everyone has resulted in greater involvement for them in the daily life of the home. A new key worker system has been developed, and a key worker and a co-key worker are assigned to each service user, who each have responsibility for ensuring that appropriate care is provided. Monthly meetings are held, on-going assessment is undertaken, any changes are monitored over a period of time, and records are amended when necessary. Risk assessments are completed, in relation to the premises, to all the activities undertaken by service users, and any restrictions imposed, and also about every aspect of the life of each resident. The details relating to risk assessments are well documented, and were last reviewed in June 2006. Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 & 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service Service users help to plan their lives. Each person takes part in various activities, and they are able to choose what they want to do and when, and this helps to ensure that their rights are respected. The opportunities made available to service users, and their regular contact with family and friends, enables them to live a full and satisfying life as far as possible. There is a flexible approach to the provision of a healthy diet, and service users are encouraged to decide what to eat and when. Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 15 EVIDENCE: Service users living at the home are encouraged to follow an ‘ordinary’ life style as far as possible, by using the same facilities as other members of the community, and being involved in a range of leisure activities, although for some of the service users a little extra encouragement is needed at times. For example, one service user likes to ‘hibernate’ in the winter, when it’s cold and wet, although will occasionally go out – only this morning a walk to the local shop to do some food shopping had been achieved, and he was very proud of this, having received much praise from everyone. A programme of activities for each person is produced, and reflects their preferences, although the need for additional opportunities has been identified by the acting manager. For example, a service user who loves music may enjoy attending some music sessions, if this can be arranged, so this proposal is being followed up at present. One service user likes to go to the pub for egg and chips and coffee and a brandy, and one resident likes to go to church, so regularly attends the Sunday services at the local church, and any coffee mornings held there. Another person loves animals, so visits to a sanctuary and the West Midlands Safari Park have been been arranged. Attending the snoezlan is also enjoyed. Various outings are organized and these can be planned in advance, for example, to the Walsall Illuminations, or perhaps on the spur of the moment, someone might suggest going out for a ride in the car. Cinderella, the pantomime at the Swan Theatre this year, was enjoyed by all. In addition some service users like cooking, playing ten pin bowling, going to the cinema or a disco, or to the pub, or just shopping in town. Further options for service users are being explored with staff at the home, and arrangements for future holidays are currently being planned. Holiday destinations this year have included Blackpool and Burnham-on-Sea. One service user who does not like going away on holiday just goes out for day trips, and has been to Weston several times and to visit his brother. Links with family and friends are promoted, and staff offer support to service users and their family, who are all encouraged to be involved with the home. Everyone has relatives, although some live a long way away. E.g. one service users father lives in America so the possibility of having contact by email is to be explored, and another residents father is in a nursing home in Wales, where arrangements have been made to visit occasionally. Food provision has been reviewed to more accurately reflect the preferences of each service user. General food stocks for the home are purchased each week with the involvement of service users. Changes to menu planning, and to food preparation are being proposed, to further promote the independence of service users. Baveney Road, 24 DS0000018627.V317860.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): 18,19,20 & 21 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The care that is provided at the home revolves around the service users who live there, and their complex needs are understood and met in an appropriate way. The manner in which support is provided by staff helps to ensure that the rights of service users are respected, when meeting their personal and health care needs. The procedures for the administration of medication ensure that the health of service users is promoted, and that they are protected. The training provided for staff has increased their awareness in relation to the ageing process and possible illness and death of a service user Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 17 EVIDENCE: The personal care needs of service users are identified, and there is evidence to show how staff understand and respond to them in an appropriate way. Reviews are undertaken regularly with all service users to determine their specific needs. A recent review identified the need for an assessment by the occupational therapist of a service users mobility that had recently deteriorated, therefore a referral has been made. The healthcare of service users is closely monitored, and additional specialist support and advice is sought from the primary health care team, and other health professionals, when necessary. The individual plan of care records the level of personal and healthcare attention needed by each person within the home. Everyone is also supported by staff to attend for routine dental appointments, sight tests and for chiropody treatment. Health Action Plans have not yet been implemented for service users living at the home. The inspector was told that arrangements had been made on two previous occasions for staff to have the necessary training to enable them to introduce these plans, but the trainer had cancelled the sessions. Further arrangements are being made in the near future. Medication arrangements at the home are satisfactory, and regular checks are made in the home by the local Pharmacist. The Medication Administration Records were seen and had been completed to a high standard, and training has also been given to staff A profile has been developed to include the side effects of each medicine, and a photograph of the service user is attached. Procedures are also in place for giving PRN (as required) medicines. A procedure is in place for dealing with the death of a service user. Staff confirmed that they had undertaken training on death and bereavement, in order to increase their awareness of these issues, and to enable them to deal sensitively with the possible terminal care or death of a service user. Baveney Road, 24 DS0000018627.V317860.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 & 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are able to express any concerns, through an effective complaints procedure. Staff know what they should do to protect service users from all forms of abuse. EVIDENCE: A clear procedure for the investigation of complaints has been produced and any issues are dealt with immediately, although there have been no complaints made about the service during the past year. The document has been produced in a format that is understandable to service users, and comments received at the home are also recorded, which helps to give a balanced view of the service. An appropriate procedure is in place relating to the many aspects of abuse and the protection of vulnerable adults, and all staff had received training as part of their induction process. Discussions with staff showed they had an awareness of these issues, and also an understanding of their individual role as an advocate for service users. Baveney Road, 24 DS0000018627.V317860.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): 24,26,29 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is comfortable and clean, and ensures as far as possible that the safety and wellbeing of service users is promoted. The décor and furnishings are in good condition, and provide service users with an attractive and homely place to live. The equipment provided at the home for service users helps them to be as independent as possible. Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 20 EVIDENCE: The premises at 24, Baveney Road is a large detached house with accommodation on two floors, which is maintained to a satisfactory standard, and is suitable for its purpose, although there are some parts of the house that would benefit from some additional attention. The inspector was told that the premises are to be decorated throughout this year, and this will deal with the problems caused by a leak from the first floor bathroom, which damaged the ceiling in the lounge. The acting manager reported her concerns about the contractor failing to respond to the emergency situation with sufficient urgency, and the potential for service users being adversely affected as a result. The home does not have double-glazing to the windows, and although they appear to be in a satisfactory condition, their replacement would improve facilities at the home quite considerably. There are four single occupancy bedrooms for service users, which all comply with space and furnishing requirements, and one room is provided with an en suite facility. The rooms are furnished to reflect the personality of their occupants, and some have sensory equipment specific to their individual needs. Several items previously identified as needing to be replaced, have been purchased including a mattress and also carpeting in the bedroom of a service user. The home is nicely decorated and comfortably furnished throughout, and there is a large lounge and a separate dining room, which also contains several items of sensory equipment for the use of service users. Appropriate equipment is provided for the use of service users, and contracts are in place for the servicing of equipment at the home, which is all in working order. The garden is well kept, and provides a suitable place for service users during the warmer weather, although several steps have to be climbed as the area is terraced. A narrow patio area can be accessed through a French window from the lounge, and there is also an aviary that has been built for a service user who has an interest in birds, and this will be used in the warmer weather. The home is clean and fresh and staff confirmed they are familiar with the procedures regarding to the control of infection, and that they have been given training in health and safety matters. There are no outstanding requirements following the most recent visit of the Environmental Health Officer. Baveney Road, 24 DS0000018627.V317860.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): 34 & 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has an experienced and competent team of staff, who are able to ensure that the needs of service users living at the home can be effectively met. Appropriate recruitment procedures ensure that service users are supported and protected by staff. The training programme available to staff ensures that they understand their role, and therefore are able to provide appropriate care and support to service users. Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 22 EVIDENCE: Dimensions provides relevant information for staff on joining the organisation, and also keeps them updated on new developments and any changes that take place. Each member of staff is given a Welcome Pack that contains details about the organisation, and its aims and objectives, an Employee Handbook that provides information about terms and conditions of employment and policies and procedures, and an Induction Checklist covering the first three months of employment. Service users and staff benefit from the thorough recruitment and selection procedures that are implemented by the organisation, which include a commitment to equal opportunities. Criminal Record Bureau checks are completed prior to an appointment being confirmed, and verbal and written references are also obtained. Staffing arrangements at the home are now more settled although there have been some changes during recent months. Some staff have transferred to and from other Dimensions’ homes in the area, one person has been on extended sick leave, and there has also been some recruitment. A new member of staff joined the team this week, and confirmed to the inspector that she was given an appropriate induction. The acting manager said that appropriate staffing levels are maintained to provide for the identified needs of service users, and that now there is limited use of relief or agency staff. A training programme is in place at the home that includes statutory and specialist care related training. Induction and Foundation training, (known as ‘Welcome to Our Team’), and the Learning Disability Award Framework (LDAF) accredited training are available to staff. The training needs of staff are regularly reviewed, and those spoken to by the inspector confirmed that they are given ‘good training opportunities.’ A record is maintained in respect of the training received by each member of staff. Baveney Road, 24 DS0000018627.V317860.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 good This judgement has been made using available evidence including a visit to this service. Satisfactory management arrangements at the home enable service users and staff to benefit from a well run home. The rights of service users are safeguarded by the effective policies and procedures, together with appropriate records that are maintained at the home. The health, safety and welfare of service users is promoted and protected in respect of all safe working practices Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 24 EVIDENCE: The care management responsibility for the home is now being undertaken by Ms Julie Bedford, who joined Dimensions almost 12 months ago. An application for registration was submitted and is anticipated in the near future. The induction arrangements have been very extensive for the acting manager, who confirmed that she has been well supported since taking up her appointment. There is clear evidence of effective person centred care being delivered, and the home is being managed in a manner that is fully inclusive of service users. The positive interactions observed between staff and service users are pleasing to observe. The home very obviously revolves around the people it is supporting. The quality assurance and monitoring systems for the Organisation includes an annual development plan for the region, and for each home, that involves service users together with the staff team, and which is part of the ongoing development of the Person Centred Planning process. Known as PATH (Planning Alternative Tomorrows with Hope), it has identified where people are at, where they would want to be in 12 months time, who they will need to help them to get there, the building bricks and the strengths needed, the first steps and who will do what. Reviews take place every 3 months, to determine what has been achieved, and what still has to be done. The outcomes are measured, the results collated, and an annual report produced. Records are maintained to a satisfactory standard at the home, and those seen by the inspector were up to date, and in good order. There was evidence found during the inspection of the home being well organized. The policies and procedures are reviewed and updated regularly, and the contents of all documents are discussed with service users and staff. Representatives attend the Regional Advisory Forum Celebration events. A comprehensive health and safety policy and procedure is in place, and staff are trained in safe working practices. An officer is employed by Dimensions to advise on health and safety matters, and the home also has a health and safety representative, with delegated responsibility for ensuring that risk assessments are reviewed regularly and implemented. The home has not received a recent visit from the Fire Safety Officer. The Fire Log Book was seen, and appropriate checks have been undertaken with the required frequency. The Fire Risk Assessment has been reviewed and updated recently. Fire awareness training is provided for staff, and fire practices and evacuation are undertaken regularly. Baveney Road, 24 DS0000018627.V317860.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 3 2 3 3 X 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 3 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X X 3 X Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard YA14 YA17 YA19 YA24 YA42 Good Practice Recommendations The opportunities for service users to increase their activities should be further developed The independence of service users should be further promoted in regard to the provision of food Health Action Plans should be implemented for all service users Consideration should be given to replacing the windows with double glazed units A reliable contractor should be used to ensure that an appropriate response is provided in an emergency Baveney Road, 24 DS0000018627.V317860.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. 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