Inspection on 24/10/08 for 29 Briants Avenue

This inspection was carried out on 24th October 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

29 Briants Avenue 15/11/06

29 Briants Avenue 29/11/05

29 Briants Avenue 14/06/05

29 Briants Avenue 30/11/04

29 Briants Avenue 07/06/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 12/03/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: 29 Briants Avenue 29 Briants Avenue Caversham Reading Berkshire RG4 5AY     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Stephen Webb     Date: 2 4 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 33 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 33 Information about the care home Name of care home: Address: 29 Briants Avenue 29 Briants Avenue Caversham Reading Berkshire RG4 5AY 01189479795 01189723479 dw@disabilities-trust.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): The Disabilities Trust Name of registered manager (if applicable) Ms Shanta Sharma Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users to be accommodated is 3. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD). Date of last inspection Brief description of the care home 29, Briants Avenue is operated by The Disabilities Trust. The home provides residential care for three adults (male and female) with Autistic Spectrum Disorder. Service Users are encouraged to overcome the disabling effects of their Autism and associated conditions, by participating in a variety of daytime activities and life experiences that promote and develop independence. The home is a three bedroomed semi-detached house, sited near the centre of Reading with local shops and facilities within walking Care Homes for Adults (18-65 years) Page 4 of 33 care home 3 Over 65 0 3 Brief description of the care home distance. The home has its own transport and easy access to the public transport system. Care Homes for Adults (18-65 years) Page 5 of 33 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This inspection included an unannounced site visit from 09:45 until 16:45 on the 24th of October 2008. This report also includes reference to documents completed and supplied by the home, and those examined during the course of the site visit. The report also draws from conversation with the manager. Residents provided some verbal feedback and the inspector also observed the interactions between residents and staff at various points during the inspection. The inspector examined the majority of the premises, including residents bedrooms. Fees at the time of this inspection were 1396 pounds per week. Care Homes for Adults (18-65 years) Page 6 of 33 Care Homes for Adults (18-65 years) Page 7 of 33 What the care home does well: What has improved since the last inspection? What they could do better: The Service User Guide could be in a more accessible format. Care Homes for Adults (18-65 years) Page 8 of 33 Some duplication within the various care plan formats will be addressed when the new person centred plans are introduced. An up-to-date copy of the local procedure for safeguarding vulnerable adults should be obtained and regular training updates should be provided for all staff in this aspect. The current toilet facilities are inadequate for residents needs as the only communal toilet is within the homes only bathroom, and is therefore not accessible when the bathroom is in use. Improvements in training regularity and planning are necessary to ensure that all staff are fully up-to-date in key areas to maximise their ability to meet the needs of residents. The providers quality assurance systems do not yet include seeking structured feedback from residents and other stakeholders. The provider needs to arrange a service of the fire detection and alarm system and copy the resulting certificate to the Commission. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 33 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 33 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents or their representatives have satisfactory information available to enable them to make an informed decision about the appropriateness of the service, though the service user guide could be in a more accessible format. The service has an appropriate pre-admission assessment process in place to establish whether the needs and aspirations of a prospective resident could be met. Evidence: The Statement of Purpose for the service had been reviewed in January 2008 and copied to the Commission. A satisfactory Service User Guide was also in place, though the document format could possibly be improved to make it more accessible to residents. All of the current residents have lived at the home for over twelve years so no recent assessment documents were available to evidence the current pre-admission assessment process, but the manager described an appropriate process as per the Care Homes for Adults (18-65 years) Page 11 of 33 Evidence: written procedure. The assessment of a prospective resident is undertaken by a senior manager within the Trust, together with the home manager, who visit the person where they are living, and complete a written assessment format. The introduction process includes a planned transition, with visits of increased duration being made to Briants Avenue. Care Homes for Adults (18-65 years) Page 12 of 33 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The needs and preferences of individuals are refelcted in their care plans ensuring that individuals views are taken into account when planning their support. Residents are encouraged to make decisions in the their day-to-day lives in order to maintain and develop their skills. Residents are supported to take risks within a positive risk assessment process, in order to enable them to maintain a fulfilling lifestyle. Evidence: The care plan files for two residents were examined in the course of this inspection. Care plan documents were comprehensive but included a variety of different formats, with some repetition between them, ahead of a planned rationalisation into a PersonCentred Plan (PCP), format. The current documents include an individual lifestyle support plan, This is me, Support documents for within and outside the home, a proactive management client profile, a service user plan, individual risk assessments and sometimes, action plans with regard to managing particular Care Homes for Adults (18-65 years) Page 13 of 33 Evidence: behaviours. It is recommended that the introduction of PCPs is used to condense the range of different documents currently in use to enable staff to more readily access the day-to-day information they need to support individuals, whilst retaining the necessary detailed information to facilitate planning and identify goals. Care plan documents had been recently reviewed, with individual documents being annotated with review dates and signatures. Copies of statutory review minutes were also on file. One resident reportedly chairs their own reviews. In one case a letter was on file indicating that the service had pursued the local authority to undertake an overdue statutory review. A staff member was heard encouraging a resident to discuss their thoughts for their upcoming review. Two of the residents take part in their reviews, and one chooses not to do so. The care planning documents clearly include the views and preferences of individuals, and describe when and how they would like to be supported, as well as referring to individual needs. It is evident that residents are involved in decision making, and this was confirmed by a resident during the inspection. The documents also include reference to positive achievements by residents, such as the completion of ASDAN college courses. Though no one is able to manage their own finances, the home operates appropriate systems to safeguard residents funds and maintains records of all transactions. This system has been improved since the last inspection. Each resident has their own bank account and cheque book, which is held on their behalf by the home. As noted above, individual risk assessments were on file for each resident, within an indexed and orderly risk assessment format. Risk assessments had also been recently reviewed. Care Homes for Adults (18-65 years) Page 14 of 33 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported to enjoy a full and varied lifestyle both within the home and the local community, and to maintain regular contact with family wherever possible. They are encouraged to take part in the daily routines of the home and to make decisions and choices in their daily lives, and are also provided with an appropriate and varied diet to maintain health. Evidence: Residents have the opportunity to take part in social and educational activities and to experience a work environment. Records confirmed that residents have attended college courses previously and currently, and one resident now travels to and from college alone via Readibus transport. Computer sessions are available at college and two of the residents have their own computers within the home. All three residents attend regular day care sessions which include sessions on art and crafts and cookery, Care Homes for Adults (18-65 years) Page 15 of 33 Evidence: and an art therapist visits the home to provide individual sessions to each resident. One resident is on work experience at a local supermarket one morning per week. Residents used to have regular swimming sessions within a specialist support but these sessions are no longer provided and the Trust is exploring other possible options. One residents family pay for them to have various private music lessons. Regular activities, day care and college attendance are indicated on individual activity schedules, which show that individuals lead a full and varied lifestyle. The manager indicated that many activities are provided individually to provide space for each resident apart from their peers, unless it is something more than one resident is interested in. Informal activities are also provided, including shopping trips, lunches out, pub trips, bowling, cinema trips and listening to music. All three residents are supported to attend a local church regularly every Sunday, where the manager indicated they are very much integrated and well known amongst the congregation. The Trust is a provider with a Christian ethos and supports residents to pursue their spiritual needs and interests. The home provides an activities room, which contains some art materials, the computers belonging to two residents and one residents piano. The art therapist also uses this room. The records within care files detailed good levels of home visits. Two of the residents go on annual holidays with family, and at present one resident does not have holidays because the Trust no longer funds them, and his family do not provide for this. The Trust should explore ways to provide for this individuals entitlement to a holiday. At present the resident does go on days out, but this is also true for the other residents. Staff support residents on family visits and regular contact by telephone, and all three residents have regular contact with family. Residents are encouraged to become involved in the daily routines and household tasks though levels of involvement vary. Residents confirmed they helped around the house with cleaning, shopping and some meal preparation. They were happy with the way staff supported them and were encouraged to make decisions for themselves. This was evidenced at lunchtime, when individuals chose what they wanted to eat, and each gets their own chosen breakfast for themselves. Residents also do their own laundry with support as required. The menus are compiled in consultation with residents and taking account of their known preferences, though staff maintain a healthy eating overview. Though residents may take part in some of the shopping and meal preparation they have little involvement in actually cooking the main meals. Owing to their busy independent lifestyles, residents do not necessarily sit down together for all meals. Care Homes for Adults (18-65 years) Page 16 of 33 Care Homes for Adults (18-65 years) Page 17 of 33 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported to meet their needs, with due regard to their wishes and preferences in order to provide dignity and fulfillment. The home also meets their physical and emotional healthcare needs. Though none of the residents is able to manage their own medication, this is managed effectively on their behalf, by the home so as to protect their welfare. Evidence: As noted above, the various care planning formats identify the needs of residents as well as any individual preferences regarding how and when they are supported. Residents make choices in their daily lives and can opt not to take part in an activity. They have opportunities to access various social, educational and employment opportunities to support their emotional wellbeing and fulfillment. Daily routines are individualised to suit each residents wishes and lifestyle, and support is offered where necessary. Where support is needed regarding specific behaviours, this is provided in consultation with external psychologist input, and how individuals convey their wishes and feelings is identified to enable staff to respond appropriately. Staff have all signed to confirm they have read and understood these documents. Each resident has their Care Homes for Adults (18-65 years) Page 18 of 33 Evidence: own bedroom doorkey, though not all opt to use this. Issues around the management of residents use of some household supplies have been explored with the psychologist with respect to one resident, resulting in the testing of a number of strategies to address the matter. However this would also benefit from further exploration with regard to the other residents, in order to explore alternatives to these items being secured by staff and only available on demand. The home has also sought support in the past from a speech and language therapist. Health care records are maintained in separate files with individual records of appointments with each health care professional. Records indicated appropriate frequency with regard to routine health care checks. The home manages the medication on behalf of the residents using a monitored dosage system. The administration records provide an appropriate audit trail for the medication and records also include GP authorisation for a homely remedy. A copy of the Royal Pharmaceutical Society guidance on medication management was available in the home, and the homes pharmacist undertook an inspection of their systems in September, from whom a report is awaited. Care Homes for Adults (18-65 years) Page 19 of 33 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has an appropriate system in place to respond to any complaints, though in the absence of any recent recorded complaints its application in practice, could not be examined. The degree to which residents are protected by the homes safeguarding practice, could be compromised by the lack of an up-to-date procedure and/or recent training in this area. Evidence: The home has an appropriate complaints procedure in place and two of the residents confirmed they knew who to speak to if they had any concerns. The procedure is also available in symbol format, though it was not clear that this enabled two of the residents to understand it. However, a copy of the procedure was present in each of the care files examined, which had been signed by the resident. The manager stated that there had been no complaints in the past year, and the Commission have not received any complaints for forwarding to the provider in that time. The absence if any recent complaints meant that the operation of the procedure in practice, could not be examined. The manager had an old edition of the local multi-agency safeguarding procedure dating from 2006. A copy of the current edition of this document should be obtained. Care Homes for Adults (18-65 years) Page 20 of 33 Evidence: The manager reported that no safeguarding issues had arisen in the home since the last inspection. The Commission has not received any safeguarding concerns regarding the home since the last inspection. The training records supplied indicated that the manager and staff had last received safeguarding training in 2006. The possibility of providing annual updates of this training for all staff should be considered, in order to ensure that staff remain up-todate on safeguarding issues. The financial recording shortfall identified in the previous inspection had been addressed to maximise the protection of residents from the risk of financial abuse. Care Homes for Adults (18-65 years) Page 21 of 33 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are provided with a good standard of accommodation to meet their needs with the exception of the inadequate toilet facilities. Laundry facilities are satisfactory and standards of hygiene in the home were good. Evidence: Briants Avenue is pleasantly decorated and homely and offers a choice of communal spaces for its three residents, between the lounge, dining room and activities room. The activities room contains the computers belonging to two of the residents, plus some art equipment and a piano belonging to one resident. Bedrooms are individually personalised to reflect the interest of the occupant. No physical adaptations are currently required to meet the needs of residents. The rear garden is a pleasant area for residents and includes a patio area as well as a lawn and borders. The home has only one communal bathroom/toilet, which is shabby and in need of redecoration to bring it up to the standard of the rest of the house. There is no separate communal toilet available, which means that the toilet is not available when the bathroom is in use. The garage was recently converted to provide a proper staff office space, which is a positive improvement. However, the additional communal toilet, originally incorporated Care Homes for Adults (18-65 years) Page 22 of 33 Evidence: in these plans was not constructed, leaving the home still without adequate toilet facilities. The provider should examine how an additional separate toilet could be provided for residents, to bring these facilities up to an adequate standard. The kitchen is satisfactory and contains the laundry facilities. Observed standards of hygiene were good. Care Homes for Adults (18-65 years) Page 23 of 33 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported by an appropriately qualified group of staff to maximise the quality of their care, and the providers recruitment practice supports and protects their wellbeing. Improvements in training regularity and planning would help to ensure that all staff are fully up-to-date in key areas to maximise their ability to meet the needs of residents. Evidence: The home has a very small staff team and most late shifts are staffed only by one individual working alone. Two staff recruited in the past year had since left the home. However, two new staff have recently been appointed to replace them, but were awaiting CRB clearance. In the interim, two long-term agency staff had been used to maximise continuity and consistency of care. The manager has attained NVQ level 4 and the Registered Managers Award, the current permanent support worker has NVQ level 3, and of the two long-term agency staff, one was undertaking a psychology degree, and the other an HND in social care, so the team are appropriately qualified and experienced. The manager indicated that the two new staff who were soon due to start, would be introduced one at a time to minimise the inevitable disruption of two Care Homes for Adults (18-65 years) Page 24 of 33 Evidence: new staff in such a small team, and enable individual attention to be given to their induction. The available recruitment records for the two recent appointees were examined to verify the providers recruitment and selection process, though both were still awaiting CRB clearance at the time. Appropriate records of recruitment were in place, including completed and signed application forms, copies of written references, copies of ID verification documents and of interview records. Appropriate evidence of immigration status was also in place where applicable. The interview process includes the completion of a written question sheet by the candidate, which is good practice. The recruitment records were held in an orderly and secure fashion. To date the residents had not been involved in the interview process, apart from observation of appointees interactions with them during their informal visit to the home. The manager should consider how the involvement of residents in the selection process for new staff could be increased. Individual training records supplied for the manager and the one current permanent staff member, indicated that although an appropriate core training had been received, some of this had taken place several years ago and had not been regularly updated since. For example, according to the individual training records, the last recorded safeguarding training was in January 2006, and fire awareness was last updated in 2003/4. The manager was not able to provide evidence of all training in the form of certificates, copies of which are reportedly held at head office. It was recommended to the manager that she retain copies of training certificates herself in order to verify her training records and ensure that updates are booked as required. The providers in house audit of staff development and training, completed in April 2008 also indicated that there was a need for an overall annual training strategy for the home, although it identified that individual training needs were discussed within supervision. The manager must ensure that all staff receive refresher training with appropriate frequency to ensure they have up-to-date knowledge in key areas, to maximise the ability of staff to meet the needs of residents, especially given the lone working arrangements, where staff have to be relied upon to work effectively in sole charge of the home. The development of an overall training strategy would enable the manager to maintain an overview of training and ensure that updates are attended with appropriate frequency. One of the long-term agency staff confirmed that they had received core training via their agency, including a recent safeguarding and whistle-blowing update, as well as Care Homes for Adults (18-65 years) Page 25 of 33 Evidence: regular supervision. Support was said to be available to staff working alone, via the manager and the providers duty on-call system, and the agency staff attend staff meetings to maintain effective communication. A record of supervision dates was available from a chart on the office wall, and the manager indicated these were usually every two months. The manager indicated that the target for team meetings was monthly but that this was not always achieved. Staff also receive annual appraisals. Care Homes for Adults (18-65 years) Page 26 of 33 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from a well managed home which is run with their best interests in mind. However, although the service is subject to a self-audit system by the provider, feedback from residents and other stakeholders is not yet central to this process. The health, safety and welfare of residents are promoted and protected, for the most part, by the systems in operation at the home. Evidence: The manager has completed her NVQ level 4 and Registered Managers Award. She has also completed a foundation management training course and attended a range of training updates in the past year to maintain up-to-date knowledge. The manager provides an on call service to the homes staff in addition to the providers duty manager system. She is able to delegate appropriate responsibilities to established staff members including long-term agency staff, who also undertake lone working on late shifts as they are now well known to residents, having worked for around two years at the home. Both permanent and agency staff receive supervision and support Care Homes for Adults (18-65 years) Page 27 of 33 Evidence: from the manager and are part of team meetings to maintain continuity of care. A series of management audits have taken place over recent years, undertaken by other service managers, focused on specific aspects of the service. Copies of the most recent audits were supplied, including those on social wellbeing, dated 2003, medication, dated 2004, user focused service delivery, dated 2005, kitchen health and safety from 2007, and staff development and training also dated 2007. A further review of social wellbeing was reportedly due in April 2009. Since the last inspection work has been undertaken to develop an overall annual service review process, and a draft format was provided during the inspection, which is due to be piloted elsewhere within the providers services. However, the provider has yet to establish a comprehensive quality assurance system at Briants Avenue, which seeks feedback from residents and other relevant parties in a structured way and leads to a summary report of its findings. The provider must continue the development of the quality assurance programme to address these shortfalls as the views of residents and other stakeholders, form an essential part of the cycle of self-monitoring, review and development of the service. A copy of the report arising from such a survey should be provided to the Commission. The manager had a business plan (annual development plan), dating from 2007/8, but a revised document for 2008/9 had not been produced. The manager undertook to devise an up-to-date development plan, and to undertake a local quality assurance survey ahead of the introduction of a system by the provider. The provider undertakes regular monthly Regulation 26 monitoring visits and produces the required reports of these visits, which were available for inspection within the home A sample of health and safety-related service certification was examined as part of this inspection. The majority of servicing had taken place with appropriate regularity but it was not possible to evidence that a service of the fire alarm had taken place since 2006. The manager indicated that there had been problems with the service provided by the previous contractor and that a new contractor had recently been engaged and a service visit was being arranged. A copy of the certification for the upcoming service of the fire alarm system should be forwarded to the Commission. The manager had reviewed the fire risk assessment in January 2008, though the document was not dated. It is recommended that all such documents are dated and signed to enable appropriate review. Weekly tests of the fire alarm are, however, undertaken by staff and recorded. The homes accident records are maintained within a collective file which enables management monitoring, though it is recommended that copies are also filed within the relevant case records as part of each residents history in the home. Care Homes for Adults (18-65 years) Page 28 of 33 Care Homes for Adults (18-65 years) Page 29 of 33 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 30 of 33 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 35 18 The manager must ensure that all staff receive the necessary training updates to maintain current knowledge in key areas. In order to ensure they maintain awareness of current best practice to maximise the quality of care provided. 11/02/2010 2 39 24 The provider / manager must establish a comprehensive quality assurance system which seeks the views of residents and other stakeholders. In order to demonstrate that the views of residents and others, about the home are central to the future planning of the service. 13/03/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of Care Homes for Adults (18-65 years) Page 31 of 33 improving their service. No. Refer to Standard Good Practice Recommendations 1 23 The manager should obtain a copy of the current multiagency safeguarding procedure, and ensure that all staff receive safeguarding training with appropriate frequency, in order to maintain their current knowledge and maximise the protection of residents. The provider should examine the available options for providing an additional separate communal toilet facility to ensure that adequate toilet facilities are available to residents at all times. A copy of the summary report arising from a quality assurance survey or residents and other stakeholders, should be provided to the Commission. A copy of the certification resulting from a service of the homes fire alarm and detection system, should be provided to the Commission. 2 24 3 39 4 42 Care Homes for Adults (18-65 years) Page 32 of 33 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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