CARE HOME ADULTS 18-65
Kingsley Road (29,31,33) 29-31 Kingsley Road Chippenham Wiltshire SN14 0BF Lead Inspector
Malcolm Kippax Key Unannounced Inspection 30th August 2006 10:30 Kingsley Road (29,31,33) DS0000028374.V298595.R02.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 Kingsley Road (29,31,33) DS0000028374.V298595.R02.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. Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Kingsley Road (29,31,33) Address 29-31 Kingsley Road Chippenham Wiltshire SN14 0BF 01249 445763 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) H4037@mencap.org.uk Royal Mencap Society Ms Caroline Powney Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (4), Physical disability (4) of places Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th October 2005 Brief Description of the Service: Kingsley Road (29, 31 and 33) provides care and accommodation to eight adults with a learning disability. Some service users also have a physical disability. Kingsley Road is run as a single establishment, although the accommodation is provided in three detached bungalows. The largest of the bungalows accommodates four people and the other two bungalows are each shared by two people. The bungalows were purpose built in 1993 and are owned by the Knightstone Housing Association. Each bungalow is self-contained with its own kitchen, bathroom, communal rooms and area of garden. Service users have their own rooms. There are wash hand basins within the rooms, although there are no separate en-suite facilities. Service users receive support from the manager, a deputy manager and a team of support workers. Staff are based in the largest of the bungalows where there is an office/staff sleeping-in room. Kingsley Road is in a residential area of Chippenham, approximately 10 minutes walk from the town centre. The scale of charges as at July 2006 was £584.67 - £991.15. Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit to the home, which took place on 30 August between 10.30 am and 5.20 pm. A second visit was arranged with the home’s manager in order to complete the inspection and to give feedback. This took place on 13 September between 5.10 pm and 6.50 pm. Each bungalow was seen on 30 August and the service users were met with during both visits. There were individual meetings with the manager and with two support workers. The home’s deputy manager was met with on 13 September. A number of the home’s records were looked at. Other information has been received and taken into account as part of this inspection: • • • • The manager completed a pre-inspection questionnaire about the home. Seven service users completed surveys about what it is like to live at Kingsley Road (some service users received support with this from staff or a close relative). Comment cards were sent to the service users’ relatives and seven of these were returned. Comments have been received from the local Community Team for People with a Learning Disability. The judgements contained in this report have been made from the evidence gathered during the inspection, including the visits to the home. What the service does well:
The support that service users require is well described in individual plans. This helps to ensure that staff have good information about the service users’ current needs and wishes. The home communicates well with other parties who are involved with the service users and in meeting their care needs. Service users benefit from the home’s approach to risk taking and independence. They said that the staff listen and act on what they say. Within the bungalows, service users can spend time by themselves within a supportive environment. Some service users are able to prepare their own meals and all service users help to choose the menus. Service users can make decisions about what they want to do. They have different routines, which include a mix of planned activities and unstructured time. Service users can spend time with their key workers, either to discuss matters that concern them or to have individual support outside the home. At the time of the first visit one service user went out with her key worker for lunch and to have a haircut. Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 6 Service users are part of the local community and go into town on a regular basis. Service users receive support with their personal relationships. Their relatives are satisfied with the care and support provided. Staff support service users with health appointments and regularly meet as a team to discuss any changes in the service users’ needs and what action needs to be taken as a result. Service users have the opportunity to raise concerns and are listened to by staff. A complaints procedure is well publicised. Staff have information and an awareness of abuse, which helps to protect service users. The accommodation meets the service users’ needs and provides a homely environment that promotes their independence. Service users are well supported by individual staff. Mencap provides training for staff, which helps to ensure that service users are protected and have their rights respected. The home is run by an experienced and competent manager. The management approach is well focused on the needs and interests of each service users. Quality assurance is being well developed. The views of service users and others are being sought and acted upon. The health & safety of service users are protected by the systems in place. What has improved since the last inspection?
The system of individual planning has improved. There is a greater emphasis put on following up the service users’ personal goals and aspirations, which are now more clearly highlighted within the service users’ plans. These developments reflect a more person centred approach to supporting service users. Individual service users are developing the skills that are needed for more independent living. Service users are better protected following changes that have been made in the way that medication is dealt with in the home. These include, for example new lists of homely remedies that can be taken by service users and regular checking of the medication records to ensure that any errors in administration are quickly found and acted on. A bathroom has been improved by the fitting of a new floor. Service users’ mobility and independence has been helped by the fitting of some new aids and adaptations, such as handrails. On-going improvements and the general success of the service is being looked at more closely as part of new approach to quality assurance. Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 7 Changes have been made in the way that records are kept, which makes them more easily accessible to the people who need to see them. 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. Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 was not looked at during this inspection. There have been no changes in occupancy since the standard was last inspected in May 2005. Standard 2 was met at that time. EVIDENCE: Kingsley Road (29,31,33) DS0000028374.V298595.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during the visits to the home. The system of individual planning is improving. Service users have individual plans, which provide good information about their current needs and personal goals. Service users are consulted by staff and encouraged to take an active role in the home. Service users benefit from the home’s approach to risk taking. EVIDENCE: Three of the service users’ care and support records were looked at. Each service user had an individual support plan, which was being reviewed every 2 – 3 months. The plans showed where risk assessments had been undertaken in respect of particular activities, such as bathing, use of a mobile phone and walking out without staff support.
Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 11 It had been recommended at the last inspection that the format and presentation of the individual plans should be reviewed, in order to reduce duplication; promote the input of service users; and develop meaningful goal setting and evaluation. Since the last inspection the system of planning has developed, with a greater emphasis put on identifying the service users’ personal goals and aspirations. These are now more clearly highlighted within the individual plans and progress is monitored through monthly key worker meetings. There was some variation in the standard of recording of these and the manager said that this was being followed up to ensure a consistent approach from staff. The local Community Team for People with a Learning Disability commented that there is now a greater emphasis on service user centred approaches within the home. The team also said that the home communicates well, particularly around the setting up of meetings to review the service users’ needs. The key worker meetings were at a time when service users could make decisions about their day-to-day support on a frequent basis. Service users were also meeting together in house meetings. The meeting minutes showed that service users have had discussions about matters that concern them and have received support with resolving problems. In their surveys, six service users stated that the staff ‘always’ listen and act on what they say. One service user stated that this is ‘usually’ the case. Service users were able to take part in some activities that involve a degree of risk. Service users in two of the bungalows spend time without staff present and can experience what it is like to be independent in their own accommodation. Service users had received support and advice about personal safety while on their own, for example when dealing with somebody who comes to the front door. This was evident when the bungalows were visited. Kingsley Road (29,31,33) DS0000028374.V298595.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during the visits to the home. Service users have individual routines, reflecting their interests and personal preferences. They have the opportunity to maintain and develop skills. Service users make use of community facilities and are supported in their relationships. Service users take responsibility in their daily lives and are consulted about the menus and what they want to do. EVIDENCE: In their surveys, the service users stated that they could do what they want during the day, in the evenings and at weekends. In practice, service users had routines during the week that included a mix of planned activities and unstructured time. Service users regularly attended local day centres, clubs and a local college. One service user said that she was on a computer course. Two of the service users met with had said in their surveys that they would like to talk to the inspector. One of these service users said that she would like to do more things outside the home. With the service user’s permission, this was
Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 13 raised with the manager, who confirmed that she would meet with the service user to discuss what would be possible. The service user in question had recently had to cancel a holiday in Spain because of a health condition. A holiday that did not involve flying was now being arranged. Another service user was very keen on football and followed a local team. He was well supported with this and attended matches regularly. Service users were engaged in different activities at the time of the visits. At the start of the visit on 30 August some service users were out attending day activities. One service user had a home-based day and was able to get up in their own time. Two service users were spending time in their own bungalow and had plans for the day which included going out with their key worker and visiting the hairdresser. The service users who returned home later in the day quickly settled into their own routines. On the 13 September the inspector joined service users for tea in one of the bungalows. A service user from another bungalow was visiting and joined in the meal. The meal was freshly prepared, consisting of baked potatoes with different fillings and a salad that one of the service users had helped to make. One of the service users had done some baking earlier in the day and shared what she had made as part of the meal. Fresh fruit was also available. The meal arrangements were flexible, taking account of service users who came in late or were going out. One service user had been on a day trip to Stratford upon Avon. Another service user left to go to a Gateway Club in the evening and was looking forward to meeting people there. The service users in another bungalow said that they take it in turns to cook meals for themselves. Staff members said that in their role of key worker they liaised with the service users’ families and provided support with relationships. In their comment cards, the relatives confirmed that they are welcome to visit at any time and can meet with their relative in private. They also felt that they are kept informed of important matters affecting their relative in the home. The records showed that service users have regular contact with family and friends, where they have such relationships. It was also evident from the records and from discussion during the visits that service users are supported in their dealings with neighbours and local people who they come into contact with, which may not always be positive. Service users were encouraged to participate in the various daily tasks within their own bungalows. This included choosing what they want to eat and preparing their own meals. The level to which each service user did this varied, depending on their own abilities and strengths. The service users in one bungalow in particular were practising lifeskills, which could lead to them being able to live in a more independent type of accommodation. In their comments, the local Community Team for People with a Learning Disability stated that there was room for improvement in the home’s support for people
Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 14 to increase independence, with a view to moving on. The inspector was told that this was not meant as a criticism of current practice, but was a suggestion for how the service could develop further. The home’s manager said that work was being undertaken with one service user, with a view to them moving on and acknowledged that progress had been slower than expected; however this was as a result of the service user’s own feelings and motivation, rather than a lack of support from the staff team. Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected 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 from evidence gathered before and during the visits to the home. Service users receive support that helps to ensure that changes in their health and personal care needs are identified and appropriately responded to. Service users are protected by the home’s procedures for dealing with medication. EVIDENCE: The service users’ care needs were recorded in their individual support plans, which were reviewed on a regular basis. Changes in need were discussed during the key worker meetings and the support plans amended accordingly. The minutes showed that the service users’ health and welfare is talked about in detail during staff meetings. The key worker system was discussed with two service users and they thought that it was good to have somebody in this role and to be able to have individual time with. The bungalow arrangements enabled support to be provided on a flexible basis according to need. Staff members were readily on hand to support some service users. Other service users could be more independent in their
Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 16 accommodation, but able to receive assistance at agreed times or when asked for. The two service users occupying one of the bungalows said that they are happy with the level of support that they receive. They mentioned times when staff came over to ‘check’ things. The practical arrangements meant that service users could receive support in the privacy of their own accommodation. A staff member summed up the team’s approach as ‘supporting, not doing for’ Details of health related appointments were recorded in the service users’ files. Examination of three files showed that service users had recent contact with GPs and other healthcare professionals, indicating that they received appropriate support with routine appointments and when occasional health concerns arose. In their comment cards, the service users’ relatives and visitors said that they are satisfied with the overall care provided in the home. None of the service users managed their own medication and support workers were taking responsibility for its administration. Service users had completed consent forms for this and their medicines were kept securely. One support worker met with said that she had attended a course on medication and had shadowed another member of staff before taking responsibility in this area. The medication administration records were up to date. Wherever practicable, two staff members signed the record when medication was administered. Changes in the medication procedures had taken place following the recommendations that were made at the last inspection. These included the production of new ‘homely remedies’ lists, which have been agreed with the service users’ GPs. It was noted from the staff meeting minutes that a handover sheet had also been introduced which included a check of medication. The manager said this was designed to ensure that any errors concerning the administration of medication could be quickly identified and followed up. This record was up to date. Other information had been recorded in relation to individual service users. For one service user this included an allergies list and another service user visited a clinic regularly for a routine check, which could result in a change in their prescribed medication. Two service users in one bungalow were asked about what they did independently and there was discussion about whether they could take some responsibility for managing their own medication. The service users felt that at the present time they were happy for staff to support them with this. Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected 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, although there was a shortcoming in how a particular incident was followed up. This judgement has been made from evidence gathered before and during the visits to the home. Service users have the opportunity to raise concerns and are listened to by staff. A complaints procedure is well publicised. Resources have been produced to assist with making a complaint although it would be beneficial to check whether each service user has this information readily at hand. Staff have an awareness of abuse that helps to protect service users. EVIDENCE: Mencap has produced an organisational complaints procedure. Informal information about how to make a complaint was displayed within the bungalows. This included photos of people within Mencap whom service users are familiar with and could contact if they wished to complain. Service users were also advised of the red pre-printed post cards, which Mencap have designed as a means by which service users can let the organisation know that they wish to talk with somebody. This was discussed with the service users in one of the bungalows. They were aware of the red card system but one service user was not sure if they had the cards. The home has not received any complaints during the last year. The minutes of house and key worker meetings showed that service users are raising concerns and receiving support with resolving these. This includes support with relationships and disagreements that arise between people who share a bungalow.
Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 18 Each of the relatives who completed comment cards confirmed that they are aware of the home’s complaints procedure. The staff members met with confirmed their awareness of the local procedure for the protection of vulnerable adults and said they had been given a copy of the ‘No Secrets’ guidance booklet. All Mencap staff attend training on abuse awareness and protection, as part of their core induction and foundation learning. The manager and staff team have experience of making a referral under this procedure. The Commission has been notified of relevant matters relating to incidents in the home and the protection of service users. Since the last inspection this has included the suspected theft of money within the home. The Police were not informed of this at the time of the incident, but were notified at a later stage after the incident had been reported to the Commission. The manager said that she would have preferred to involve the Police at the time but had been advised that Mencap would carry out their own investigation into the disappearance of the money. In their surveys, the service users stated that they feel safe at Kingsley Road, and know who to speak to if they are unhappy about anything. Kingsley Road (29,31,33) DS0000028374.V298595.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during the visits to the home. Service users live in homely surroundings. The accommodation meets the service users’ needs and promotes their independence. The bungalows are kept clean and in good order, although the gardens would benefit from tidying up. The management and staff team monitor the suitability of the environment. However the benefits for service users are reduced by the way in which maintenance work needs to be arranged. EVIDENCE: The three bungalows provide self-contained accommodation and facilities for independent living. The bungalows have been adapted to varying degrees for people who may have a physical disability. Some new aids and adaptations, such as handrails have been fitted since the last inspection. Depending on their individual needs and abilities, service users either live in a bungalow where staff are present throughout the day, or in a bungalow where they are visited by staff or can summon assistance from staff by telephone or call alarm system. The service users in the ‘unstaffed’ bungalows confirmed
Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 20 how they could contact staff and said they were happy with these arrangements. The three bungalows looked clean and hygienic to a reasonable standard. However, an area of lounge carpet in one of the bungalows was stained following a drinks spillage. Initial shampooing of the carpet had not been successful in removing the stain, so it will need to receive further attention. Each bungalow had its own area of garden, some parts of which looked overgrown. Service users said they had chosen the décor in their own accommodation. Mencap do not own the bungalows and the home is dependent upon a housing association for the carrying out of repairs and maintenance work. The manager and staff identify items in need of attention and had a ‘jobs list’ for work that needed to be dealt with by the housing association. The manager said that the home experiences delays in the carrying out of work and that several items have needed to be chased up. Since the last inspection, the Commission has been informed of difficulties in completing the refurbishment of a bathroom, which had left service users without their usual facilities for a while. The manager said that this was to be discussed at a meeting that had been arranged with an officer from the housing association. Kingsley Road (29,31,33) DS0000028374.V298595.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is adequate and improving. This judgement has been made from evidence gathered before and during the visits to the home. Service users are well supported by individual staff. The staff team has undergone a number of changes in recent months, although a more settled period is anticipated. Service users benefit from the training and support that staff receive. Service users are protected by the home’s recruitment procedures. EVIDENCE: There are staff on duty at all times when service users are at home. This includes a minimum of two people on each shift. At night there is one person on waking duty and one person ‘sleeping-in’. Staff are always present in one of the bungalows, where service users have the highest level of need. Support is provided, as required to service users in the other two bungalows. Staffing levels have been reviewed during the last year, to take account of the service users’ assessed needs. In their comment cards, six relatives stated that they were of the opinion that there are always sufficient staff on duty. One person commented that they ‘don’t know’.
Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 22 It was reported at the last inspection that the staffing situation was improving after a period of staff turnover, which had created some instability. New staff had been recruited and the final checks were being made on other prospective starters. These staff were subsequently employed although there have continued to be changes in the staff team. Four support workers have left since the last inspection, two of whom did not complete their probationary periods. Mencap relief staff were covering shifts in the home until new permanent staff are recruited. There has been some success with the appointments made during the last year. This has included a deputy manager and a new support worker, who were both met with during the visits. All staff met with spoke positively about their work and were optimistic about how the staff team was developing and supporting the service users. Mencap provides new staff with a comprehensive induction programme, which is consistent with national standards for the social care workforce. This covers the organisation’s key values and philosophy of care, as well areas of statutory training. A staff member who had started since the last inspection said that she had attended Mencap training courses titled ‘Respond and Respect’, which concerned communication, and ‘Protect and Respect’, which covered abuse awareness. Following induction, staff members are expected to attend courses in accordance with Mencap’s staff training and development plan, which includes enrolment for a National Vocational Qualification (NVQ). At the time of this inspection, five people had achieved NVQ level 2 or above, which is over 50 of the staff team. There was a staff training needs assessment, which gave an overview of the training that each person had undertaken and identified timescales for the completion of new courses and refresher training. Training in Dementia care and epilepsy are planned to take place in the coming months. Examples of two staff members’ employment records were looked at. The recruitment procedure included checks with the Criminal Records Bureau and with the staff members’ previous employers. Application forms had been completed, although on one of these the section about references had not been completed. The manager said that this was because the staff member’s application had been ‘fast-tracked’. References had been received in respect of this staff member, although the system of ‘fast-tracking’ had resulted in the referees’ details not being included in an important employment record. Some files and records have been reorganised and made more accessible, as recommended at the last inspection. Kingsley Road (29,31,33) DS0000028374.V298595.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made from evidence gathered before and during the visits to the home. Service users benefit from an experienced and competent manager. Quality assurance is being well developed. The views of service users and others are being sought and acted upon. The health & safety of service users are protected by the systems in place. Action is being taken when new risks arise. EVIDENCE: The home’s manager, Caroline Powney, has been in post since October 2000. Caroline Powney has achieved NVQ level 4 in care and said that she is expecting to complete the Registered Managers Award by the end of the year. The deputy manager has been in post since October 2005 and her responsibilities had increased over time. The deputy role is seen as an opportunity for career development and the post holder undertakes training to
Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 24 the same level as a registered manager. The deputy manager was working on her NVQ portfolio during the visit to the home on 13 September. The staff members met with were very positive about the support that they receive in the home, which one person described as ‘brilliant’. The home was implementing Mencap’s organisational approach to quality assurance. This had undergone a number of changes during the last year, with a greater focus being put on continual development and improvement. The system included input from a number of people including service users, staff and manager. The feedback received contributed to a ‘Continual Improvement Plan’, which was reviewed and added to on a regular basis. The plan set out how areas, such as support for service users, the staff team, systems and the environment could be made better. The needs of wheelchair users and improvements to the medication procedures had been identified in the current plan that was seen. The backgrounds and personal circumstances of service users were being considered in the planning of their support, in addition to their particular disability. When asked about equality and diversity within the home, the manager mentioned the importance of ensuring that the needs of the youngest service user are recognised, as the home mainly provides support to service users in an older age range. The manager spoke about another service user who could be at risk of not being included in activities because they did not make the same demands on staff as other service users. Targets had been set to help ensure that the service user was not unintentionally excluded. Staff members’ gave examples of how health and safety was monitored within the establishment. This included checks of the hot water and the fire precautions. Key workers carried out a monthly check of rooms with the service users to look out for hazards such as damaged electrical appliances and trailing cables. Gas, electrical and hoist servicing had taken place during the last year. The fire logbook showed that the alarms are being regularly tested and that staff receive instruction in fire precautions. A fire risk assessment was carried out in September 2005. Other risk assessments had been undertaken in areas such as home security and uncovered radiators. Some recent incidents had resulted in the installation of some additional safety measures within the bungalows, in order to increase security. Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 x 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 x ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 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 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 x x 3 x Kingsley Road (29,31,33) DS0000028374.V298595.R02.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. 1. Standard YA23 Regulation 13(6) Requirement Incidents involving theft or the suspicion of theft must be reported to the Police without delay. Timescale for action 31/08/06 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. Refer to Standard YA6 Good Practice Recommendations That a more consistent approach is taken in the recording of the progress that service users make with meeting their goals and aspirations. That the service users’ individual plans and related records are produced in a more user-friendly format. That a check is undertaken to ensure that each service user has the information and resources they need in order to make a complaint.
DS0000028374.V298595.R02.S.doc Version 5.2 Page 27 2. YA6 3. YA22 Kingsley Road (29,31,33) 4. YA34 That the details of a prospective staff member’s referees are always recorded on their application form for employment. Kingsley Road (29,31,33) DS0000028374.V298595.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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