CARE HOME ADULTS 18-65
29, 31, 33 Kingsley Road 29-31 Kingsley Road Chippenham Wiltshire SN14 0BF Lead Inspector
Malcolm Kippax Unannounced Inspection 5th December 2007 12:35 29, 31, 33 Kingsley Road DS0000028374.V351542.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 29, 31, 33 Kingsley Road DS0000028374.V351542.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. 29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service 29, 31, 33 Kingsley Road Address 29-31 Kingsley Road Chippenham Wiltshire SN14 0BF 01249 445763 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) www.mencap.org.uk Royal Mencap Society Vacant 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 29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 30th August 2006 Brief Description of the Service: Kingsley Road 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. Support staff are based in the largest of the bungalows, where there is an office and staff sleeping-in room. Kingsley Road was without a registered manager at the time of this inspection. Ms Susan Yearly was the acting manager and there was also a deputy manager. The scale of charges was £584.67 - £991.15 per week. A copy of the last inspection report can be obtained from the home. Inspection reports are also available through the Commission’s website at: www.csci.org.uk 29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection included an unannounced visit on 5th December 2007 between 12.35 pm and 5.45 pm. A second visit was arranged with Ms Susan Yearly, the home’s acting manager, in order to complete the inspection. This took place on 12th December 2007 between 10.00 am and 12.25 pm. The Inspector was accompanied by an ‘Expert by Experience’ and their supporter during the visit on 5th December 2007. An Expert by Experience is a person who uses services and who is helping the Commission for Social Care Inspection to inspect care services. The Expert by Experience’s observations are reflected in this report. Evidence was obtained during the visits through: • • • Time spent with the service users in the three bungalows. Meetings with Ms Yearly, with the deputy manager and with a support worker. An examination of records, including the service users’ care files. Other information has been received and taken into account as part of this inspection: • • An Annual Quality Assurance Assessment (referred to as the AQAA). The AQAA is the provider’s own assessment of how well they are performing. It also provides information about what has happened during the last year. Surveys that were returned by three relatives and by ten staff members. The judgements contained in this report have been made from the evidence gathered during the inspection, including the visits. What the service does well:
People’s needs are assessed before they move into Kingsley Road, so that a decision can be made about whether the home is suitable. Further information is obtained, which helps to ensure that staff know what the new service user likes to do and how they should be supported. Individual support plans are produced and kept under review to reflect any changes in people’s needs. People have different lifestyles and the daily routines are meeting their needs. The Expert by Experience thought that staff treated people as individuals and that a big age difference between the service users was not a problem. People can take part in activities that involve a degree of risk. People living in two of the bungalows spend time without staff present and can experience what it is like to be independent in their own accommodation. Some people prepare their own meals and everybody helps to choose the menus.
29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 Page 6 People are part of the local community and are supported with different activities during the week. They receive support with relationships. Their relatives are confident about the support that the home provides to people. People are supported with their health appointments, so that they can have access to specialist services and advice. The staff team regularly discuss people’s needs and welfare, so that any concerns can be quickly followed up. People have the opportunity to raise concerns and are listened to by staff. There are procedures that help to protect people from harm. The three bungalows are purpose built and part of a relatively new development. They are in a well established residential area and it is easy for people to get to their different activities in the local community. The bungalows have been adapted so that they meet people’s needs. An occupational therapist had recently been consulted in respect of one person’s needs. Each bungalow has its own area of garden. People said that they liked their accommodation. The Expert by Experience thought that the smaller of two bungalows they saw was particularly homely, with people having their own personal things ‘all over the place’. Mencap provides training and produces guidance, so that people in the home are supported by competent staff. The home’s recruitment procedure helps to ensure that people are not supported by unsuitable staff. People can make suggestions about new things that they would like to do. There is a quality assurance system which helps to maintain good standards and to identify improvements that could be made. What has improved since the last inspection?
The bungalows provide people with the opportunity to be independent in their own accommodation. The bungalow are self-contained and have facilities which people can use to develop their domestic and lifeskills. In the smaller bungalows, service users can also experience what it is like not to have a staff member directly on the premises. Since the last inspection, this arrangement has helped one person to achieve their goal of moving from the home to a more independent form of living A new system of checks and recording has been introduced for monitoring standards in the bungalows’ kitchens. This helps to ensure that the food is safely kept and that service users benefit from facilities that are properly maintained. It was reported in the AQAA that some of the home’s administrative and recording procedures have been changed. As the result of this, information was reported to be more accessible to people and easier to understand. Most of the records seen during the visits were well presented.
29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 Page 7 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. 29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is adequate overall. This judgement has been made using available evidence including the visits to the home. People have their needs assessed before moving into the home. They do not receive all the information that they should about how services and goods are paid for. EVIDENCE: One new service user had moved into Kingsley Road since the last inspection. Correspondence and the records made in connection with the move were kept on a personal file that had been set up for the new service user. The home had received a needs assessment and care plan from the person’s placing authority. Information had also been obtained from another service where the person had received respite care before moving to Kingsley Road. Further information about the prospective service user had been gained when they visited the home. All the information received had been used to produce guidelines for staff about how this person should be supported, for example when bathing. Risk assessments were undertaken and a support plan produced shortly after the person moved into the home. The contents of the service user’s guide were discussed with Ms Yearly. Information had not been included about the arrangements being made for charging and paying for any services that are not covered by the weekly fee.
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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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including the visits to the home. People are well supported with their individual needs and with making decisions. They would benefit from better information being recorded about their personal goals. EVIDENCE: Three people’s care and support records were looked at. Each person had an individual support plan, which had been reviewed in recent months. The plans showed where risk assessments had been undertaken in respect of particular activities, such as mobility, going out and how people managed their money. Each person had a key worker from the staff team. People met with their key workers every month to talk about the progress they were making and changes that might be needed to their support plans. Notes of the meetings were kept and these showed what action had been decided. The Expert by Experience was told that there was a big age difference between the service users.
29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 Page 11 Initially the Expert by Experience was concerned about this and wondered how people could be supported with doing what they wanted. They concluded at the end of their visit that the age range did not seem to be an issue. The Expert by Experience felt that what came across was that staff treated people as individuals. People talked to their key workers about their personal goals. These had been recorded on separate forms within people’s individual files. Some goals, such as going horse riding and having a train journey to Weymouth, had been recorded in the last few months. Other goals were recorded in 2006. It was not always clear whether the older goals were still relevant. Ms Yearly said that some of the goals had been achieved and could now be incorporated into people’s on-going support plans. The forms had a section for identifying whether a risk assessment was relevant to a particular goal. This had not always been recorded. Service users spoke about some of the goals they had achieved, such as having a holiday and going on outings. House meetings were being held when service users could talk about things together and make decisions. Each bungalow had its own meetings and minutes were being kept. At a meeting in November 2007, people talked about having their gardens tidied up and what they would like to do over the Christmas period. The meeting agendas included the item ‘Inclusion’. This involved people being asked if they felt that were as involved as they wanted to be in the day to day routines. The Expert by Experience thought that it might be beneficial if the house meetings were sometimes facilitated by an independent advocate, rather than by one of the staff. They also commented that although one person went to a disability network meeting, people did not seem to know about any local People First groups. In their surveys, the relatives stated that they felt that people’s needs were always met by the home. They also thought the home supported people to live the life that they chose. People were able to take part in activities that involved a degree of risk. Service users in two of the bungalows spent time without staff present and could 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. 29, 31, 33 Kingsley Road DS0000028374.V351542.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): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including the visits to the home. People have individual lifestyles and the daily routines are meeting their needs. EVIDENCE: Some people were out when the home was visited and other people were having home-based days. The activities outside the home at the time included being at college, at day centres and shopping with staff. Peoples’ support plans showed that their week included a mix of planned activities and unstructured time. The Expert by Experience commented that, when they arrived, some people had just got back from their day activities and other people had not gone anywhere that day through their own choice. The Expert by Experience said that they observed people ‘watching television, having a drink and chatting to staff’. They thought that the atmosphere was ‘warm and friendly’ and that people were relaxed. 29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 Page 13 People had their own room keys and front door keys. It was evident from talking to service users in the two smaller bungalows that they liked the independence of having their own self-contained accommodation. One person said that they were looking forward to having a new person move into their bungalow. Visits were being planned so that the two people could see how they got on. Information about people’s spiritual needs, family backgrounds and their significant relationships was included in their personal files. Part of the key worker role was to support service users with their relationships and to liaise with their families. In their surveys, the relatives stated that they felt they were kept informed of important matters affecting their relative in the home. They also confirmed that the home helped their relative in the home to keep in touch with them. People were encouraged to participate in the domestic tasks within their own bungalows. Since the last inspection, one person has achieved their goal of moving from a care home to a more independent form of living. One of the current service users was also developing their lifeskills, with a view to moving to a more independent type of accommodation. They prepared most of their own meals. People in the other two bungalows received more support with their meals. Sometimes, staff prepared the meals for people in one of the smaller bungalows. The Expert by Experience commented: ‘In the main bungalow, everyone has support to do activities in the day. Many have high support needs and find it difficult to cook and clean but one resident likes to and is encouraged to help prepare meals. Everyone is supported to make their lunchboxes’. Menus were being written in conjunction with the service users. People could talk about the meals when they met together at the house meetings. 29, 31, 33 Kingsley Road DS0000028374.V351542.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 good. This judgement has been made using available evidence including the visits to the home. People’s personal care and health needs are met. They receive the support that they need with their medication, although further information in respect of self-administration would be beneficial. EVIDENCE: People’s care needs were recorded in their individual support plans. Changes in need were discussed during the key worker meetings and the support plans amended accordingly. It was seen from the minutes of staff meetings that people’s health and welfare were regularly discussed. This meant that staff could share any concerns and decide together how best to follow these up. The bungalow arrangements enabled support to be provided on a flexible basis according to need. Staff members were readily on hand to support people in the main bungalow. Other people could be more independent in their accommodation, but able to receive assistance at agreed times or when it was asked for. People said that they were happy with the level of support that they received. They mentioned times when staff came over to check things.
29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 Page 15 The practical arrangements meant that service users could receive support in the privacy of their own accommodation. With their permission, one person’s personal diary was looked at in their bungalow. Staff had written in the diary when they had visited the bungalow and commented on what the person had done and how they were. It was agreed with Ms Yearly that more specific information should also be recorded, such as the time of the visit and the support that they had provided at the time. Details of health related appointments were recorded in people’s individual files. The records showed their recent contact with GPs and with other healthcare professionals. Staff members said that they supported some people with nail cutting and other people received support from outside the home. They confirmed that nobody had to pay for podiatry or chiropody services. Guidelines had been produced for staff about the service users’ specific health needs, such as epilepsy. Health action plans were being completed with people. Mencap had produced a set of forms for this. Ms Yearly said that the process was going to be completed by the end of December 2007. In their surveys, the relatives confirmed that the home gave people the care and support that they expected or had been agreed. People received support with managing their medication. This involved staff administrating their medication and keeping it securely on their behalf. People had completed consent forms. Staff did not administer medication until they had received training in the procedures. The medication administration records were up to date. Staff members completed a handover sheet, which included checking the medication stocks four times a day. This was designed to ensure that any errors concerning the administration of medication could be quickly identified and followed up. The support plan for one person included taking some responsibility for managing their own medication. This was part of their plan to be able to live more independently. Some stages had been identified, which the person would need to complete in order to achieve greater independence with their medication. It was agreed with Ms Yearly that some of the terms used should be made clearer, so that there could be no misunderstanding about what the service user was able to do for themselves. The home had a policy on medication, which included the procedure that needed to be followed if a person was taking some responsibility in this area. 29, 31, 33 Kingsley Road DS0000028374.V351542.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 the visits to the home. People have the opportunity to raise concerns and are listened to by staff. There are procedures that help to protect people from harm. EVIDENCE: Mencap had produced an organisational complaints procedure. Information about how to make a complaint was displayed within the bungalows. This included photos of people within Mencap whom the service users would be familiar with and could contact if they wished to complain. The policy on complaints included giving service users a complaints pack, which contained a number of red pre-printed post cards. Mencap had designed this ‘red card’ system’, as a means by which service users could let the organisation know that they wished to talk with somebody outside the home. This was discussed with a service user in one of the bungalows and they were aware of how the cards were to be used. The home had not received any complaints during the last year. The minutes of house meetings showed that service users were being asked whether they had any concerns and were able to discuss these. Each of the relatives who completed surveys confirmed that they are aware of the home’s complaints procedure. Staff attended training on abuse awareness and protection, initially as part of their induction programme.
29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 Page 17 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. The home has had experience of making a referral under this procedure. In their surveys, the staff members confirmed that they knew what to do concerns were raised with them about the home. A number of checks, for example of people’s personal money accounts, were being undertaken on a regular basis. These were designed to protect the service users’ interests. 29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including the visits to the home. The accommodation is meeting people’s needs and enables them to exercise independence. EVIDENCE: The three bungalows were part of relatively new development in a well established residential area of Chippenham. Each bungalow had its own area of garden. They provided self-contained accommodation and facilities for independent living. The bungalows had been adapted to varying degrees for people who may have a physical disability. An occupational therapist had recently been consulted in respect of one of the service user’s needs. Dependant upon their individual needs and abilities, service users either lived in a bungalow where staff were present throughout the day, or in a bungalow where they were visited by staff or could summon assistance from staff by telephone or call alarm system. People in the ‘unstaffed’ bungalows confirmed how they could contact staff if they needed to.
29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 Page 19 The call alarm system was not used very often. Staff said that the system used to be tested regularly, but thought that this had not happened for a while. A new system of checks and recording had been introduced since the last inspection for monitoring standards in the bungalows’ kitchens. This helped to ensure that the food was kept safely and that the facilities were working as they should be. The three bungalows looked clean and hygienic to a reasonable standard. However, the kitchen in one of the bungalows would benefit from a more thorough clean. Service users in the two smaller bungalows said that they did most of the cleaning. An environment health officer had visited in November 2007. Ms Yearly said that action had been taken as a result of this, including getting a new fridge for one of the bungalow kitchens. The Expert by Experience commented: ‘In the main bungalow (4 residents) the décor was a bit like a “home”. Residents said staff had done the decorations. There were lots of photos of residents about. In the smaller bungalow (2 residents) it was much more “homely” with residents there having their own personal things all over the place’. People in the largest bungalow had their evening meal together in the dining area, which was connected to the kitchen. It was seen that the space around the dining table was quite limited, particularly for people who were using wheelchairs. This was discussed with Ms Yearly and the deputy manager, who recognised the problem. They suggested that the other, larger communal room could be better used as the dining area and it was agreed that this would be worth looking into further. Mencap did not own the bungalows and the home was dependent upon a housing association to carry out repairs and maintenance work. 29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including the visits to the home. People are supported by competent staff and are protected by the way that new staff are recruited. EVIDENCE: Mencap provided new staff with an induction programme that was consistent with the national standard for the social care workforce. The induction covered the organisation’s key values and philosophy of care, as well areas of mandatory training. One of the staff members spoken with had recently started working in the home. They described the induction that they had received and how they were working alongside other staff members before able to work by themselves. Following induction, staff members were expected to attend courses in accordance with Mencap’s staff training and development plan. This included enrolment for a National Vocational Qualification (NVQ). There was a staff team of eleven at the time of this inspection, of whom six had achieved a NVQ at level 2 or above. 29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 Page 21 Mencap arranged training courses for staff in a variety of subjects, including first aid and manual handling. Ms Yearly said that a training plan for the year ahead was currently been written with the home’s deputy manager. Each staff member had an individual training and development record. In their surveys, staff members commented positively about the training and support that they received. They confirmed that the appropriate checks had been undertaken before they had started work. The employment files were looked at for two staff members who had been appointed since the last inspection. These files were well organised and contained a range of relevant records, such as written references, medical fitness forms and copies of documents confirming the applicants’ identity. The recruitment procedure included obtaining a disclosure from Criminal Records Bureau (CRB) and checking the Protection of Vulnerable Adults (POVA) list. Mencap had obtained information from the applicants as part of diversity monitoring. 29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good overall. This judgement has been made using available evidence including a visit to this service. People are benefiting from a well run home. The home was without a registered manager at the time of this inspection. The future management arrangements need to be confirmed, so that people can continue to have confidence in how the home is being run. EVIDENCE: The registered manager left the home at the end of October 2007 to move to another post within Mencap. Ms Susan Yearly was managing the home in an acting capacity, while she continued to have responsibility for another Mencap run service. Ms Yearly said that a decision had not yet been made about the future arrangements for managing the home. A number of options were being considered. A meeting was to be held in the coming week to look at these, after which time a proposal was to be put to the Commission. 29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 Page 23 The home had a deputy manager who had been in post since October 2005. This role helped to provide continuity in the running of the home. The deputy manager demonstrated a good knowledge of the service users’ needs and of procedures in the home. The time that they spent on management and administrative tasks had increased, as the acting manager was not working full-time in the home. The deputy manager had attended a number of training courses, including supervision, that were relevant to their post. The home was implementing Mencap’s organisational approach to quality assurance. This focussed on continual development and improvement. The system included input from a number of people including service users, staff and the 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. One of the improvements identified was to produce people’s support plans in more accessible formats. A representative from Mencap visited the home to carry out a monthly quality review. Information about health and safety arrangements was included in the AQAA. Health and safety matters were being discussed during the house meetings and staff meetings. These included security issues and lone working by staff. Service users were given information at the house meetings about the home’s fire procedures. There were fire risk assessments for each of the bungalows. These had been reviewed in September 2007. Assessments had been undertaken in respect of other hazards, such as hot surfaces. The risk assessment records were numbered and kept in a file. A risk assessment for the radiators in one of the bungalows was missing from the file. Ms Yearly confirmed that she would follow up its whereabouts and confirm this with the Commission. Some regular maintenance checks were being carried out in the bungalows. A chart was seen in one of the bathrooms. Staff had completed this when they checked the temperature of the hot water. 29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 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 2 2 3 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 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 X 3 X X 3 X 29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 Page 25 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 YA1 Regulation 5(1) Requirement The service user’s guide must include the arrangements being made for charging and paying for any services and goods that are not covered by the fees. Timescale for action 29/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations That the service users’ current goals, and their progress with achieving these, are more clearly recorded within their individual files. This will help ensure that staff have up to date information and are consistent in the support that they provide to service users. That the advocacy issues raised by the Expert by Experience are followed up, as they highlight ways in which service users could feel more empowered. That the recording of the visits that staff make to people in their bungalows is more objective and includes more specific information, such as the time of the visit and the support that they had provided at the time. This will provide a better means of monitoring the level of support
DS0000028374.V351542.R01.S.doc Version 5.2 Page 26 2 3 YA7 YA18 29, 31, 33 Kingsley Road 4 YA20 5 YA24 that people need and how they are managing. That the arrangements being made for a service user to manage some of their own medication are more fully described in their support plan. This is so that there can be no misunderstanding about what the person is able to do for themselves and what support they require from staff to do this safely. That the call alarm system is tested on a regular basis. This is because it is infrequently used and needs to be kept in good working order. 29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Regional Office Colston 33 33 Colston Avenue Bristol BS1 4UA 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 29, 31, 33 Kingsley Road DS0000028374.V351542.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
