Inspection on 16/01/07 for 28 Southdown Road

This inspection was carried out on 16th January 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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

28 Southdown Road 29/11/05

28 Southdown Road 31/08/05

28 Southdown Road 11/01/05

28 Southdown Road 17/08/04

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

CARE HOME ADULTS 18-65 28 Southdown Road Seaford East Sussex BN25 4PG Lead Inspector Niki Palmer Unannounced Inspection 16 January 2007 12:00 th 28 Southdown Road DS0000021001.V322362.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 28 Southdown Road DS0000021001.V322362.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. 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 28 Southdown Road Address Seaford East Sussex BN25 4PG 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) 01323 897877 southdownrd@onetel.com Southdown Housing Association Limited Ms Marion Love Care Home 5 Category(ies) of Learning disability (5) registration, with number of places 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is five (5). Service users must be aged between eighteen (18) and sixty five (65) years on admission. Only adults with a learning and physical disability are to be accommodated. 29th November 2005 Date of last inspection Brief Description of the Service: 28 Southdown Road is a care home, which provides personal care and accommodation for up to five residents with physical and learning disabilities. It was opened in 1997. The home is owned and run by Southdown Housing Association who are a large voluntary organisation that have been providing services to people with learning disabilities across East Sussex for over 16 years. The home is a large purpose built bungalow situated in a quiet residential area of Seaford. It is close to the town centre and public transport facilities, although the home does have access to two wheelchair-friendly vehicles. All rooms are for single occupancy with hand washing facilities in addition to two large assisted bathrooms. There is a large lounge, spacious kitchen/dining room and a well-maintained, secure garden to the rear of the property. The home is well decorated and maintained throughout and has a friendly and homely atmosphere. The home provides personal care and support to residents who are funded by Social Services. The home’s fees as of 04th January 2007 are £1582.00 per person per week. Additional costs are charged for hairdressing (£6-8), hydrotherapy (£variable), some toiletries (£variable) and holidays (£variable). Prospective residents and their relatives are provided with written information regarding the services and facilities provided at the home prior to admission. A copy of the home’s most recent inspection report is available on request from the home. 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at 28 Southdown Road will be referred to as ‘residents’. This unannounced inspection took place on Tuesday 16th January 2007 and lasted approximately six hours. Five residents were accommodated on the day of the inspection, all of which were male and aged between 31 and 40 years of age. The majority of the inspection was facilitated by the Registered Manager. In order to gather evidence on how the home is performing, individual discussions took place with six members of staff, including the Deputy Manager and the Organisation’s Area Manager who visited the home during the afternoon. Two care records were examined in some detail for the purpose of monitoring care. Other records and documentation inspected included: the home’s Statement of Purpose and Service Users’ Guide, medication practices, the provision of activities, quality assurance systems, complaints procedure and the systems in place to safeguard residents from harm, staffing levels and the provision of relevant training. All communal areas and individual rooms were seen. A detailed pre-inspection questionnaire was received prior to the visit to the home. This provided the Inspector with information relating to the residents accommodated, premises, maintenance and associated records and details of the homes policies and procedures. Five residents’/relatives survey questionnaires were sent to the home prior to the inspection, two of which have been returned, completed on behalf of residents by their relatives. What the service does well: 28 Southdown Road is a well-managed service. The dignity and rights of residents to lead an ordinary life in the community underpin the ethos and development in the home. Residents are supported by a skilled, well-trained and effective staff team who are knowledgeable about the needs and support required for each resident. Despite residents’ verbal communication being limited, staff have learned to interpret individuals’ subtle level of communication, needs and wishes. Residents lead a varied and fulfilling lifestyle both at home and in their local community in order to meet and develop personal needs, choices and aspirations. 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 6 The home has been specifically adapted for people with physical learning and sensory disabilities. A great deal of time, money and effort has been dedicated to ensuring that residents live in a homely and comfortable environment. Comments received from relatives include: ‘All his needs are clearly documented in his records. He is very happy at his home and has a good rapport with his carers’. “The staff are caring, professional, kind and cheerful”. “He is well looked after, all his needs are met. We have no complaints”. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 28 Southdown Road DS0000021001.V322362.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 28 Southdown Road DS0000021001.V322362.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 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 and others are provided with sufficient information prior to admission in order to support their decision of where to live. Good systems are in place to ensure that only residents whose needs can be met are admitted to the home. EVIDENCE: The home has a detailed Statement of Purpose and Service Users’ Guide in place, both of which have been updated since the last inspection. The Statement of Purpose provides the reader with an introduction to Southdown Housing Association, details of the Registered Manager, staffing structure and overall service provision including: the accommodation, the arrangements for residents to engage in social and leisure activities together with any therapeutic techniques, the arrangements for dealing with concerns or complaints and the systems for ensuring that residents’ needs are identified, met and reviewed in accordance with person centred planning. The Service Users’ Guide is presented in an easy to read and understand format, which incorporates the use of pictures and symbols. It gives an overview of the philosophy of care, purpose of the service, accommodation and outlines what support and care individuals can expect from the home. Both of the survey questionnaires that were returned by relatives confirmed that they 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 9 feel they received enough information prior to admission in order to help them to make a decision about whether the home could meet their relative’s needs. One person commented: “Yes as a parent I did receive the right information. 28 Southdown Road proved to be the right home”. Most of the residents currently accommodated have lived together for a number of years in other establishments prior to moving in to 28 Southdown Road in 1997. The compatibility of residents is at this time good. Albeit that there have been no new admissions to the home since the last inspection, the Manager was able to describe in detail the arrangements in place for assessing all prospective residents and to ensure that they are given the opportunity to visit the home prior to moving in; this could involve staying at the home for a day, overnight or several shorter visits. 28 Southdown Road DS0000021001.V322362.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, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by the home’s care planning procedures, however the home should consider reviewing the current format in order to make them more user-friendly. Staff have a good understanding of residents’ needs. Clearly assessed and managed risks enable residents to undertake a wide range of activities. EVIDENCE: Two individual plans of care were examined in some detail for the purpose of monitoring care. Detailed pen portraits/life pictures and individual’s likes and dislikes are recorded, although the current care planning format is quite difficult to understand and follow as the home currently uses a number of different recording methods. In addition to the care plan, separate daily entries are kept, additional healthcare records, a daily diary, personal records and additional separate monthly summaries. It was therefore not possible to clearly audit and establish how residents’ needs were currently being met, although it must be noted that all care staff spoken with demonstrated a 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 11 detailed understanding and knowledge of individuals’ needs. It is strongly recommended that the home review it’s current care planning and recording systems in order to determine if they can be simplified. In addition the home must ensure that that as individual’s needs change, their plans of care are amended accordingly in respect of residents’ health and welfare. The Manager was reminded that all records must be signed (including the person’s surname) and dated by the person completing them. All of the residents living at the home have complex physical and learning disabilities and are therefore reliant on care staff, their relatives and other health and social care professionals to act in their best interests and make decisions on their behalf about many aspects of their lives. Relatives confirmed that they are involved in this process as much as possible. Albeit that residents’ verbal communication is limited, staff working in the home were observed to interpret individuals’ subtle level of communication and include residents in the daily routines of the home wherever possible. One relative commented: “Although he has few communication skills, his likes and dislikes are clearly noted”. There was documentary evidence of detailed risk assessments and management plans to enable residents to undertake a wide range of activities in the home and in the community including hydrotherapy and using a wheelchair. Risk assessments are also in place for specified healthcare needs such as epilepsy and medication. Those seen had recently been reviewed and updated as necessary, however the home is required to ensure that additional information is included for the use of bed rails in order to ensure that any potential risks to individuals are identified and the appropriate action is taken. All confidential information is stored securely. 28 Southdown Road DS0000021001.V322362.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): 11, 12, 13, 14, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported to take part in a wide range of activities to lead fulfilling lives, meet their needs and ensure their personal development. Residents play an active and fulfilling role in their community and maintain positive relationships with family and friends. The ethos of the homes promotes the right of residents to make choices in all aspects of their lives to the best of their abilities. EVIDENCE: Residents are supported to access a wide range of opportunities and activities both within the home and in their local community. Three residents attend structured day services, although care staff are currently in the process of reviewing these, whilst others go to college. All of the residents have a day during the week where they spend time at home, often on a one-to-one basis with staff where they do their household tasks. A relative commented: 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 13 “The daily routine is programmed to meet his needs”. The home has access to two vehicles, which can accommodate wheelchairs. This enables residents to go out and explore different areas in and around the county. Staff confirmed that weekends and evenings are flexible; residents can choose to stay at home and relax, go to a music club, attend parties at other nearby residential homes run by Southdown Housing Association, go swimming, horse-riding, meals out, go to the pub, shopping, or use a sensory room – also owned by Southdown Housing Association. All residents are supported to go away on holiday with care staff at least once a year. Destinations have included Paris, Devon and Ireland. Each of the returned questionnaires received by relatives and conversations with staff confirmed that visitors are always made to feel welcome to the home and there are no restrictions placed on visiting times. Throughout the duration of the inspection all staff were observed to knock on residents’ bedroom doors prior to entering and address them by their preferred term as indicated within individual plans of care. No residents at this time have an appointed advocate, but all residents are supported by their relatives and care staff to exercise their rights and choices. All meals are prepared within the home by care staff who have attended a Food Hygiene course. Residents are encouraged to participate in food preparation to their best of their abilities. No person at present requires a specialist diet i.e. vegetarian or low in sugar, although all residents are offered discreet support as necessary at all mealtimes. Residents are encouraged to dine together in the large kitchen/dining area, however those who choose to do so, can remain in the lounge. 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. Staff provide sensitive and dignified support to meet the individual needs and preferences of residents. Residents are mostly supported to access a range of healthcare services to meet their physical and emotional well-being. Residents are on the whole safeguarded by the homes policies and procedures for the safe administration of medicines. EVIDENCE: All residents are registered with a local General Practitioner (GP) and dentist and are supported to all appointments as necessary. Due to the complex healthcare needs of residents, specialist advice from the Community Learning Disability is sought on an individual basis including physiotherapy, nursing and speech and language therapy. All personal care is carried out in the privacy of one of the communal bathrooms or in residents’ own bedrooms. Baths/showers are carried out at flexible times according to the preferences of each individual. 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 15 All of the residents living at the home have epilepsy. It was pleasing to note that the majority of staff have received training in this area including the administration of emergency medication. Further training from a Community Nurse has been organised for the very near future. Whilst individual guidelines are in place to support staff in managing residents’ seizures, it was concerning to note that one person whose epilepsy has been well controlled for a number of years, does not have any guidance in place for staff to follow. In addition, despite him experiencing a seizure recently (the first for many years), the home failed to notify the GP, or update his plan of care accordingly. The home is required to ensure that individual epilepsy management guidelines are in place for all residents. These must include a brief history of the person’s seizures, a description of what form the seizure takes and instructions for staff to follow in the event of a seizure occurring. A sample of the home’s medication procedures and records were seen. The home uses a pre-packed blister pack, which is delivered by the local pharmacy on a monthly basis. The Manager of the home confirmed that only staff who have received the appropriate training dispense medicines, whilst either the Manager, Deputy or senior carer hold responsibility for re-ordering and checking medications in to and out of the home. As a measure of good practice, the home has written detailed information for staff to follow, which indicates the reasons why each of the medicines are prescribed and what their possible side-effects are. None of the residents accommodated are able to self-medicate. Whilst records inspected were found to be accurate, it was not possible in two instances to identify the expiry dates on medicines that had been prescribed in liquid form. Whilst this is not solely an error on behalf of the home, the home must ensure that it has sufficient systems in place to check for these. 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 16 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 good systems in place to ensure that all complaints are dealt with appropriately. Residents are protected from potential harm, neglect and abuse through the home’s robust policies and procedures and through staff receiving appropriate training. EVIDENCE: The home has a detailed complaints procedure in place, which is included within the home’s Statement of Purpose and Service Users’ Guide. It gives clear guidance with regards to how a complaint can be made and how the complainant can expect it to be dealt with. Relatives confirmed that they would feel confident in raising any concerns on behalf of their relatives. No complaints have been received by either the home or the CSCI since the last inspection. The home has a detailed Adult Protection and whistle-blowing policy and procedure in place in accordance with local multi-agency guidelines. Staff spoken with confirmed that recent training has been provided by the Organisation and that they would feel confident in reporting any concerns of suspected abuse and poor practices within the home. No alerts have been raised since the last inspection. The Manager acts as an appointee for all five residents. The home holds residents’ personal allowances at the home, which all care staff have access. A sample of these were randomly checked and found to be in order. 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 17 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, 25, 26, 27, 28, 29 and 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, clean, well-maintained and comfortable home, which presents as personalised and homely based on individuals’ choices and needs. A good deal of communal space and bathing facilities are provided. Residents have comfortable bedrooms and various adaptations, to meet their personal needs. EVIDENCE: The Inspector was shown around all areas of the home by the Deputy Manager on the day of the inspection. The home is a large purpose built bungalow, which has been specially adapted and equipped for use for people with physical disabilities. A number of sensory equipment is provided throughout the home including individual bedrooms. All areas were noted to be clean, well maintained and warm. Under floor heating is provided throughout. One relative commented: 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 18 “28 Southdown Road is a pleasant clean home, without any smell. It’s very comfortable”. Residents’ bedrooms are personalised to individual preferences with appropriate specialist equipment in place including electrically operated beds, pressure relieving equipment for those who need it and overhead tracking for those who require support with manual handling. The home also has a manual hoist for staff and residents to use. All residents have their own TV’s, DVD’s and music systems in their rooms. The home has two large communal bathrooms with height adjustable baths, one of which has been installed since the last inspection. All hot water outlets have thermostatic valves fitted to ensure hot water temperatures do not exceed the recommended 43°C. In addition to this the home has installed speakers in the bathrooms to enable residents to listen to music whilst relaxing in the bath. There is sufficient communal space for residents to use including a large lounge area and separate kitchen/diner. The home is pleasantly decorated and furnished throughout. Any minor repairs are recorded within a maintenance book, which staff confirmed are usually promptly dealt with by the Organisation’s property services department. Planning permission has recently been agreed to extend the property to create an additional three bedrooms with en-suite facilities (two for residents and one for staff). This will increase the home’s registration numbers to seven. Residents and their relatives have been consulted in this process. It is planned that the work will commence over the summer period, when the residents will be away from the home in order to keep any disruption to a minimum. 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a skilled and dedicated staff team who continue to work hard to meet the needs of residents. Residents are supported and protected by the home’s robust recruitment procedures. The staff team are supported to provide consistent care and meet the needs of residents through regular supervision and training. EVIDENCE: A total of 18 staff are employed to work at the home, eight of whom have obtained at least NVQ level 2 in Care. It is anticipated that a further four persons will commence working towards this qualification in April 2007. All care staff spoken with said that Southdown Housing Association and the Manager are very supportive in providing additional training. Recent training includes: communication, crisis intervention, working with autism, manual handling and first aid. Future training that has been organised includes: working with challenging behaviour, fire safety, person centred planning and infection control. 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 20 All staff confirmed that they have clear job descriptions and fully understand their roles and responsibilities. It was pleasing to hear that all the care staff spoken with are happy in their job and thought of the home as a ‘great place to work’. Due to the daily activities within the home, which are based on individual’s needs and choices, staff are required to work flexible shifts including sleep-in duties. Staffing rotas confirmed that there are always sufficient numbers of staff on duty in the daytime and one sleep-in person at night. Whilst this is at this time considered to be adequate, the home will need to review the night time staffing arrangements following an increase in the numbers of residents accommodated, particularly as a high proportion of residents have additional complex needs. The Manager and a number of staff spoken with said that all job advertisements are advertised in local newspapers and on the Organisation’s website. All initial information is coordinated by the Organisation’s Human Resources department who are responsible for sending out application forms, alongside the required Criminal Record Bureau (CRB) and Protection of Vulnerable Adults First (PoVA) check, health declaration and Equal Opportunities Monitoring Form. As a matter of good practice, the Manager asks all interested applicants to visit the home on an informal basis, prior to short-listing for interview in order to give the applicant a ‘flavour’ as to what they can expect working at the home. Staff spoken with confirmed that all interviews are undertaken by the Registered and Deputy Manager. The supervision of care staff is shared between the Registered and Deputy Manager. Supervision contracts are agreed and signed in advance and stored securely within the office. All staff spoken with, said that they had completed application forms prior to employment, had given the names of two referees, and had been CRB checked prior to employment. All members of staff had also received a thorough induction, training and receive regular supervision. 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 21 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, 38, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and staff benefit from a well run and organised home. The dignity and rights of residents to lead an ordinary life in the community underpin the ethos and development in the home. EVIDENCE: The Registered Manager has been in post for over four years. She holds an NVQ Level 4 certificate in Management and has obtained and Advanced Management qualification in Care. She has worked with people with learning disabilities over the past 12 years. The Manager is supported in her role by an experience Deputy Manager, who has worked at the home since it was first opened. Without exception, all of the staff spoken with and comments received from relatives indicate that they feel the home is managed well. 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 22 Seeking feedback from residents can be a challenging role for 28 Southdown Road due to individuals’ complex care needs and limited verbal communication skills. Relatives did confirm however that their views are sought on a regular basis both informally and through the use of stakeholder feedback questionnaires. In addition to this the Area Manager visits the home on a regular unannounced basis, in order to gain feedback from staff and observe the daily routines and interactions within the home. Once a year, the staff team have a ‘quality monitoring day’ whereby the team get together to audit how well the home is performing and meeting residents’ needs. Some of the areas focused on include: staff team housekeeping, support and mobility for residents, meeting healthcare needs, person centred planning and health and safety matters. Evidence provided within the home’s returned pre-inspection questionnaire identified that all equipment is well-maintained and regularly serviced including: fire equipment, gas installation, hoists, environmental health issues, electrical appliances central heating system and emergency lighting. 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 23 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 4 26 4 27 4 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 4 12 3 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 3 3 X X 3 X 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 YA19 Regulation 15(1)(2) (a-d) Requirement Timescale for action 16/01/07 2. YA9 3. YA6 YA19 4. YA20 That care plans are updated accordingly as individuals’ health and welfare needs change. All records must be signed and dated by the person completing them. 13(4)(a-c) That individual risk assessments for the use of bed rails are amended to include more detail. The appropriate action must be taken. 12(1)(a)(b) That individual epilepsy 15(1)(2) management guidelines are in place for all residents. These must include a brief history of the person’s seizures, a description of what form the seizure takes and instructions for staff to follow in the event of a seizure occurring. 13(2) That systems are in place to ensure that all medicines are 17(1)(a) Schedule regularly checked to see that 3(i)(k) they are in date. 31/03/07 31/03/07 16/01/07 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 25 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. Refer to Standard YA2 YA33 Good Practice Recommendations That the home review it’s current care planning and recording systems in order to determine if they can be simplified. That consideration is given to employing a waking night person in line with the home’s increased numbers of residents. 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 28 Southdown Road DS0000021001.V322362.R01.S.doc Version 5.2 Page 27 - 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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