Inspection on 15/06/06 for 287 Dyke Road

This inspection was carried out on 15th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

287 Dyke Road 03/09/08

287 Dyke Road 19/01/08

287 Dyke Road 23/07/07

287 Dyke Road 14/02/06

287 Dyke Road 10/08/05

287 Dyke Road 11/01/05

287 Dyke Road 27/07/04

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

CARE HOME ADULTS 18-65 287 Dyke Road Hove East Sussex BN3 6PD Lead Inspector Niki Palmer Unannounced Inspection 15th June 2006 09:50 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 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 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 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. 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 287 Dyke Road Address Hove East Sussex BN3 6PD 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) 01273 566804 www.caremanagementgroup.com Care Management Group Limited Vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That service users should be younger adults aged between eighteen (18) and sixty-five (65) years on admission. The maximum number of service users to be accommodated is eight (8). That service users to be accommodated have a learning disability, not falling within any other category. 14th February 2006 Date of last inspection Brief Description of the Service: 287 Dyke Road is a care home, which provides personal care and accommodation for up to eight residents with profound physical and learning disabilities. The home is owned and run by Care Management Group (CMG) who are a large organisation that provides care for people with learning disabilities. The home is a large detached property, which is located on a main road on the outskirts of Brighton. There is nearby access to some local amenities and to public transport. There is limited parking available at the home, but on-street parking is permitted. All rooms are for single occupancy with en-suite facilities and are located over three floors. There is a passenger shaft lift available to allow access to all floors. It should be noted that although the home complies with the required communal area, there is no communal area that can accommodate all eight residents at any given time. The home provides personal care and support to residents who are funded by Social Services. The home’s fees as of 05 May 2006 range between £1800 £2200 per person per week. Additional costs are charged for hairdressing (£10), chiropody (£10) and external activities for example shows and concerts. Prospective residents and their relatives are provided with written information regarding the services and facilities provided at the home prior to admission. The home’s most recent inspection report is kept on display at the main entrance to the home. 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 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 287 Dyke Road will be referred to as ‘residents’. This unannounced inspection took place on Thursday 15 June 2006 and lasted approximately six hours. Eight residents were accommodated on the day of the inspection, five male and three female aged between 18 and 22 years of age. In order to gather evidence on how the home is performing, individual discussions took place with the acting Manager, four members of care staff, the home’s driver and CMG’s Physiotherapist. Three 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 premises, maintenance and associated records, details of the homes policies and procedures, staffing details and relevant training. Eight residents’ survey questionnaires were sent to the home prior to the inspection, four of which have been returned, completed on behalf of residents by their relatives. Following the inspection, telephone contact was made with one resident’s advocate, District Nursing Team and two relatives. In addition, written feedback was received by a local General Practitioner. Their views are reflected throughout this report. In order that a balanced and thorough view of the home is obtained, this report should to be read in conjunction with the previous inspection report carried out on 14 February 2006. 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Three requirements are outstanding from the previous inspection. Albeit that risk assessments have been completed for unrestricted windows, the home has failed to ensure that appropriate action has been taken to safeguard residents and staff. Concerns were raised during the last inspection regarding the home’s ineffective emergency call system. Despite some action being taken, it was concerning to note that not all bedrooms, particularly those on the top floor had suitable systems in place. This resulted in an immediate requirement being issued on the day of inspection. 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 Page 7 The home has been without a Registered Manager for over one year. It is required that an application is submitted to the CSCI by no later than 31 August 2006. Many of the residents have epilepsy. The home is required to update all management guidelines for individuals and provide additional training for staff specific to the needs of residents. Appropriate action must be taken to ensure that all exposed hot water pipes do not place staff at risk, particularly when supporting residents with bathing, whilst all equipment must be checked and certified to state that it is safe for use. 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. 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 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 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives 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. Whilst residents have a statement of the terms and conditions of residency within the home, not all are available for inspection. EVIDENCE: The home has a detailed Statement of Purpose and Service Users’ Guide in place, which were seen on the day of the inspection. The Statement of Purpose provides the reader with an introduction to CMG including the home’s aims and objectives, details of the Registered Provider and Manager, organisational and staffing structure and colour photographs of the accommodation provided. The Service Users’ Guide offers a good level of information regarding the services and facilities provided, residents’ charter, contact details of the Commission for Social Care Inspection (CSCI) and the arrangements in place for health and social care support. Both documents are presented in an easy to read and understand format, which incorporate the use of colour pictures and symbols. All of the survey questionnaires that were returned by relatives confirmed that they feel they received enough information prior to admission in order to help them to make a decision about whether the home could meet their descendant’s needs. 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 Page 10 Due to the complex healthcare needs of the residents accommodated, it is crucial for the home to ensure that as much information as possible is gathered prior to admission in order to ensure that the home can meet their needs. Some of the residents currently living at 287 Dyke Road were admitted from a nearby children’s service, also owned by CMG, thus making the handover of information more accessible. One of the resident’s advocates spoken with following the inspection said that this transition period was handled ‘exceptionally well’ by the home. Other residents were initially assessed by CMG’s centrally based Assessment Referral Officers, alongside the Manager. It was pleasing to note that copies of previous school records, care plans and multidisciplinary health and social care assessments were drawn together at this time. There have been no new admissions to the home since the last inspection. The home has appropriate terms and conditions of contract for residents, copies of which are included within the home’s Service Users’ Guide, however individual copies including the fees payable could not be located during the inspection. A requirement has been made in respect of this. 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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. Residents are supported well by the home’s care planning procedures. Staff have a good understanding of residents’ needs; this is evident from the positive relationships that have been formed between them. EVIDENCE: Three individual care plans called “All about me’ were inspected. All were found to be exceptionally comprehensive and person-centred to individual needs. All areas of daily living are detailed including their complex physical healthcare needs and specific information relating to their sensory needs and likes and dislikes e.g. how they prefer to be touched when having their personal care needs carried out, how they communicate non-verbally, what smells make them feel good (aromatherapy, shampoos and other toiletries) and what sounds make them feel happy or sad for example music and loud noises. All care staff spoken with confirmed that they are involved in the regular review of care plans alongside the Manager on a three monthly basis. 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 Page 12 All of the residents living at the home have profound physical and learning disabilities and are therefore reliant on care staff, their relatives and other health and social care professionals to make decisions on their behalf about many aspects of their lives. It was pleasing to note that all care staff spoken with were familiar with best practice issues in relation to acting on a person’s behalf when it is deemed that they do not have the capacity to make an informed decision and choice. Relatives spoken with confirmed that they are consulted and involved in these decisions as they arise by the Manager and care staff. 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. Due to the profound disabilities of the residents, limited risk taking can be initiated, however detailed risk assessments are in place for all activities of daily living and personal health care needs including: administration of medication, eating and drinking, showering and bathing and epilepsy. All confidential information is stored securely. 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents lead a varied and fulfilling lifestyle, which encourages them to develop life skills and maintain relationships with family and friends. EVIDENCE: CMG owns a development centre, which is accessed by each of the nearby on a daily basis Monday to Friday. This provides opportunities for residents to engage in informative and creative activities should they wish, including sensory stimulation, art, postural movement, Speech and Language Therapy, physiotherapy, music, and IT. At weekends, dependent on the weather, the number of staff permitted to drive and accessibility of transport, residents are supported out into the local community for example to the cinema, park, walk along the seafront, shopping, pub, football match and live music concerts. Some residents go home to stay with relatives for the weekend. The organisation has four vehicles that are shared between five homes in the Brighton area, the school and the development centre. All of the staff spoken 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 Page 14 with said that this poses some restrictions for the home as due to a recent change in insurance companies the number of drivers permitted to drive the only large vehicle appropriate for needs of the residents at 287 Dyke Road has reduced significantly, consequently impacting on the number of community activities that residents can take part in. The Manager has raised these concerns with the Senior Management Team, however additional funding has yet to be agreed. As an interim measure, staffing rotas are planned in advance to accommodate this. It is strongly recommended that priority be given to providing additional transport. CMG has an indoor hydrotherapy pool located at the rear of a nearby home, however this has not been in use for over one year. The newly appointed Physiotherapist told the Inspector that he is currently in the process of putting together a proposal to get the pool up and running and back in use for each of the homes. This has involved so far liaising with pool consultants and implementing a number of risk assessments and protocols to ensure that it is properly maintained and safe to use. All staff will need to undergo a water competency test and First Aid training. This will be a valuable asset to the residents of the home. Each of the returned questionnaires and conversations with relatives and staff confirmed that visitors are always made to feel welcome to the home and there are no restrictions placed on visiting times. All visitors are requested to sign in to the home on arrival in a book located at the main entrance of the building. Due to the complex physical healthcare needs of the residents accommodated, there is only one resident at present who is able to eat food orally. All other residents have clear feeding programmes in place, which staff are trained to administer via residents’ specialist feeding tubes. A Speech and Language Therapist is responsible in assessing, planning and reviewing individual needs, including providing training to staff. Only care staff who have attended a Food Hygiene course are permitted to cook meals at the home. CMG have organised a further date for new staff to attend this training in July 2006. 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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. The healthcare needs of residents are met well by the home with evidence of good multidisciplinary working taking place on a regular basis. EVIDENCE: All residents are registered with a local GP and dentist and are supported to all appointments as necessary. The home tries to ensure as much as is possible that a member of staff is allocated to stay with residents for all hospital admissions. Due to the complex healthcare needs of residents, District Nurses visit the home on a regular basis. Feedback received from the GP and District Nursing Team confirm that they are satisfied with the overall provision of care, feel that the home communicates clearly with them and that staff demonstrate a clear understanding of the care needs of residents. 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. 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 Page 16 Some of the residents living at the home have epilepsy and whilst it was pleasing to note that the majority of staff have received training in this area including the administration of emergency medication, some of the individual guidelines were outdated and unclear. It also emerged through discussions with care staff that they were unaware of the different types of seizures that individual’s have. The home is required to ensure that such records are updated to 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. Additional training must be provided to all staff. CMG employs a Speech and Language Therapist and Physiotherapist, who are responsible for working into each of the homes, devising specialist programmes and purchasing any additional specialist equipment. Referrals are made to the local Community Learning Disability Team on an individual basis. A sample of the home’s medication procedures and records were seen. All residents are prescribed medicines in liquid form, which are administered via their specialist feeding tubes. None of the residents are able to self-medicate. The Manager of the home confirmed that only staff who have received the appropriate training dispense medicines, whilst either the Manager or Deputy hold responsibility for re-ordering and checking medications in to and out of the home. Monthly audits are carried out, records of which are kept. All medicines were found to be appropriately stored with clear and accurate records maintained. 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 and improved procedures to ensure that residents are protected from harm, neglect or abuse. 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. Since the last inspection it has been amended to include the contact details of the CSCI. No complaints have been received by either the home or CSCI since the last inspection. Following the last inspection, the home’s Adult Protection and Whistle-blowing policy and procedure were updated to clearly state that all allegations of suspected abuse must be referred to Social Services under local multi-agency guidelines. Information regarding the Protection of Vulnerable Adults (PoVA) list has also been included. Staff spoken with confirmed that in-house training was provided shortly after this 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. 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Albeit that 287 Dyke Road presents as a clean, well-maintained and homely place to live, insufficient communal areas determine that residents are unable to participate in group activities at any one time. Improved procedures need to be in place to ensure that all equipment is in good working order. EVIDENCE: The Inspector was shown around all areas of the home by one of the care staff on duty on the day of inspection. All areas were noted to be clean and well maintained. Residents’ bedrooms are personalised to individual preferences with appropriate specialist equipment in place including electrically operated beds and pressure relieving mattresses for those who need it. It was noted however, that one resident’s infrequently used suction machine had not been tested and checked to ensure that it is safe for use. An immediate requirement was issued on the day of inspection for this equipment not to be used until the satisfactory checks had been completed. The home has three bathrooms complete with assisted baths, showers and overhead tracking. Since the last inspection pre-set hot water valves have 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 Page 19 been fitted to ensure that hot water is only delivered to a maximum of 43°C. Records seen confirmed that these are tested on a weekly basis. Two of the bathrooms were noted to have exposed hot water pipes; whilst these do not pose any immediate risk to the residents accommodated, they could potentially pose a risk to staff when they are supporting residents with bathing. The home is required to complete risk assessments for all exposed hot water pipes and take appropriate action. Three of the returned questionnaires and a number of staff and relatives spoken with commented on the small communal lounge area. Although it meets the minimum requirements of the National Minimum Standards, it cannot accommodate all eight residents at any one time, due to their specialist equipment i.e. wheelchairs, lying boards and specialised seating. The Manager told the Inspector that these concerns have been raised with the Senior Management Team and that they are considering adapting or extending this area in order to make it more user friendly. It is strongly recommended that this be prioritised. Following the home’s last inspection a new call bell system was installed, however staff complained that this was over-sensitive and was being triggered by passing traffic and low-level noise within the home. This led to individual bedroom monitors being purchased. As only four can be used at any one time, the Manager confirmed that risk assessments had been completed and priority was given to the two bedrooms on the third floor of the building, yet on inspection such monitors were not in place. An immediate requirement was issued on the day of inspection for the home to ensure that the intercom system/monitors are working effectively and are suitably placed throughout the home. Following a recommendation made at the last inspection, the Manager and Care Coordinator developed a training pack for all staff regarding infection control a copy of which was forwarded to the CSCI. It covers handwashing techniques, the use of protective clothing, best practice in cleaning up blood and other spillages, the safe disposal of waste and sharp objects and specific techniques for ensuring that safe practices are followed when supporting a person with specialist tube feeds. 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 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 consistent, well-trained and supervised staff team. Recruitment procedures are improved. EVIDENCE: A total of 23 staff are employed to work at the home including: the acting Manager and Deputy, one housekeeper, five senior carers, six night staff and nine day care staff. Four have obtained at least NVQ Level 2 in Care, whilst a further six are currently working towards this qualification. Care staff spoken with said that CMG and the Manager are very supportive in providing additional training. First Aid, eating and drinking, Adult Protection, Fire Training, Health Action Planning and administration of medication are examples of different training sessions that have been attended since the last inspection. All staff confirmed that they have clear job descriptions and fully understand their roles and responsibilities. Copies of job descriptions were seen in individual recruitment files. All staff are now provided with a copy of the GSCC code of conduct and practice. This is improved since the last inspection. It was pleasing to hear that all the care staff spoken with were happy in their job and thought of the home as a ‘great place to work’. 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 Page 21 Due to the daily activities within the home, staff are required to work a minimum of one split shift per week. This is to ensure that there are appropriate numbers of staff on duty in the mornings and evenings when the majority of residents are at home. Staffing rotas confirmed that there are always two waking night staff on duty to attend to residents’ needs and carry out a number of cleaning duties including the sterilisation of equipment. Major shortfalls were identified at the home’s last inspection, in relation to recruitment procedures. Since this time the Manager has worked very hard to ensure that all the correct documentation and checks are in place for all existing and newly appointed staff including two written references, Criminal Record Bureau (CRB) and PoVA First checks. This was confirmed by the examination of three staff records. All new staff spoken with said that they had received a thorough induction to the home within their first six weeks of appointment including a two week ‘shadowing’ period with a senior member of staff. Three senior members of staff including the Manager and Deputy have received specific training to enable them to provide regular supervision sessions and annual appraisals to all staff. Supervision contracts are agreed and signed in advance and stored securely within the office. 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 Page 22 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 at least once during a 12 month period. 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. The overall conduct and management of the home is improved. EVIDENCE: The acting Manager of the home is a First Level Registered General Nurse by background and has worked for CMG for a number of years. She has been managing 287 Dyke Road since April 2005. She is currently working towards a BSc Honours in Clinical Practice, which includes a Leadership and Management Module. Without exception, all of the staff spoken with, relatives and health and social care professionals said that they feel the home is managed well. Their comments include: ‘the Manager is very approachable’, ‘very knowledgeable’ and ‘caring’. 287 Dyke Road has been without a Registered Manager for over one year. Notwithstanding that improvements have been noted in the overall 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 Page 23 management of the home since the last inspection, the home is required to ensure that an application is submitted to the CSCI for a person to become registered as the Manager of the home. Seeking feedback from residents is a challenging role for CMG 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 satisfaction questionnaires. These are coordinated by Head Office. In addition to this the Regional Operations 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. Details of these visits are forwarded to the CSCI. Staff spoken with said that they were recently asked to complete an anonymous staff survey. An incomplete copy of this was seen on the day of inspection. The areas covered include: the home’s environment, provision of residents’ food, staffing levels and teamwork, tasks associated with the job e.g. supervision, appraisals and keyworking sessions and comments for further improvements. It is anticipated that the results of this survey will be published and made available for inspection. Since the last inspection all fire doors have been repaired to ensure that they close properly. These were checked on the day of inspection and found to be in working order. In addition risk assessments have been completed for unrestricted windows throughout the home. These were discussed in detail on the day of inspection. Whilst it is acknowledged that wheelchair users are at minimal risk from falling from windows, it is imperative that the home ensures residents and staff’s safety by installing window restrictors on all of the ground floor windows to prevent intruders from gaining access. 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 Page 24 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 X 5 2 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 3 26 X 27 2 28 3 29 1 30 3 STAFFING Standard No Score 31 3 32 2 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 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 2 3 X 2 3 3 X X 2 X 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? Yes. 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 YA5 Regulation 17(1)(2) Requirement Timescale for action 31/08/06 2. YA19 3. 4. YA19 YA27 5. YA29 6. YA29 That copies of residents’ terms and conditions of contract are kept within the home and made available for inspection. These must be inclusive of the fees payable. 12(1)(a)(b) That individual epilepsy management guidelines are updated. These must include a brief history of the person’s seizures, a description of what form the seizure takes and clear instructions for staff to follow in the event of a seizure occurring. 12(1)(a) That up to date epilepsy training 18(c)(1)(i) is provided to all staff. 13(4) That risk assessments are completed for all exposed hot water pipes. Appropriate action must be taken. 23(2)(c) That the suction machine for one resident is not used until it has been certified as safe to use [IMMEDIATE REQUIREMENT]. 16(2)(c) That the intercom system/monitors are working effectively and are suitably placed throughout the home. (IMMEDIATE REQUIREMENT OUTSTANDING FROM THE DS0000060762.V291003.R01.S.doc 31/08/06 30/09/06 30/07/06 15/06/06 15/06/06 287 Dyke Road Version 5.1 Page 26 PREVIOUS INSPECTION). 7. YA32 12(1)(a) 18(c)(1)(i) 8(1) 9(2) 13(4) That the home continues to work towards having at least 50 of the care staff team qualified to NVQ Level 2. That an application is submitted to the CSCI for a Registered Manager [OUTSTANDING]. That all ground floor windows are restricted [OUTSTANDING]. 31/12/06 8. 9. YA37 YA42 31/08/06 31/07/06 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. Refer to Standard YA14 YA14 YA28 Good Practice Recommendations That priority is given to providing additional transport. That priority is given to making the swimming pool useable for residents. That consideration is given to extending/adapting the communal living area in order to make it more user friendly. 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 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 287 Dyke Road DS0000060762.V291003.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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