CARE HOME ADULTS 18-65
West Ashton Road (29) West Ashton Road Trowbridge Wiltshire BA14 7BJ Lead Inspector
Malcolm Kippax Unannounced Inspection 26th June 2007 14:50 DS0000028350.V344569.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 DS0000028350.V344569.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. DS0000028350.V344569.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service West Ashton Road (29) Address West Ashton Road Trowbridge Wiltshire BA14 7BJ 01225 766654 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) h5m001carwithen@mencap.org.uk www.mencap.org.uk Royal Mencap Society Susan Grace Carwithen Care Home 6 Category(ies) of Learning disability (6) registration, with number of places DS0000028350.V344569.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. No more than 6 service users with a learning disability which includes the 1 named male service user with both a learning disability and physical disablement currently being accommodated 10th October 2005 Date of last inspection Brief Description of the Service: 29 West Ashton Road provides personal care and accommodation for up to six adults with learning disabilities. The home is run by Mencap and a housing association owns the property. 29 West Ashton Road is in a residential area of Trowbridge. The home is a Victorian, semi-detached property on two floors. Each service user has their own room. Two bedrooms are on the ground floor and four rooms are on the first floor. The bedrooms do not have en-suite facilities. There is a bathroom on the ground floor and a shower room on the first floor. The communal areas include a lounge, a dining room, a kitchen and a separate utility room with laundry facilities. At the rear of the home there is a large garden with a lawn, shrubs and vegetable plot. Service users receive support from the home’s manager and a team of support workers. Service users attend a range of college courses and day activities in the community. The fees at the time of this inspection were £528.00 per week. Some additional charges are made, including the costs of holidays and travel. Information about the service is available in the home’s ‘Statement of Purpose’. Copies of inspection reports can be obtained from Mencap and are also available through the Commission’s website at: www.csci.org.uk DS0000028350.V344569.R01.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 26 June 2007 between 2.50 pm and 6.50 pm. A second visit was made to the home on 29 June 2007 in order to complete the inspection and to give feedback. The home’s manager, Mrs S. Carwithen, was present at that time. Evidence was obtained during the visits through: • • • Time spent with the six service users and with three members of staff. This included joining service users for their evening meal on 26 June 2007. Observation and a tour of the home. Examination of records, which included four of the service users’ personal files. Other information has been taken into account as part of this inspection: • • • • A pre-inspection questionnaire that the manager completed about the running of the home. Surveys that were received back from four of the service users’ relatives. Surveys that were completed by the service users prior to the visits. Feedback that has been received from the Community Team for People with Learning Disabilities in Trowbridge. The judgements contained in this report have been made from all the evidence gathered during the inspection, including the visits. What the service does well:
People’s needs are assessed before they move into the home. Visits are arranged so that the people living in the home can meet with prospective service users. New service users are helped to settle in. The staff team finds out more about what people like to do and their preferred routines. Individual plans are then produced, which give good information about the support that the service users will receive. The plans are produced in different formats, for example large print and an audio version, in order to meet people’s individual needs. The support plans are regularly reviewed to ensure that staff provide the support that is needed. People can make decisions about how to spend their time. They receive help with doing the things that they want to, such as going to college, shopping in the town centre or looking after a pet. Service users go out locally, either on their own or with support. They like the location of the home because they can easily get to many of their regular activities. People feel that they are part of the local community and they are learning to be more independent, for example with making journeys. Within
DS0000028350.V344569.R01.S.doc Version 5.2 Page 6 the home people participate in the daily activities, including the planning and preparation of meals. In their surveys, relatives commented positively about different aspects of the service that service users receive. One relative said that the home helped people to find suitable college courses and to develop their interests. Staff are aware of the risks involved in some of the service users’ activities. They seek to reduce these by assessing people’s abilities and whether they can be safe in the things they want to do. However, in the surveys, not all the relatives agreed with the level of independence that service users have. Mrs Carwithen said that a meeting was to be held to discuss this further. People who know the home are mostly positive about the support that staff provide and the outcome for service users. Good records are kept of the service users’ day to day needs and welfare. This helps staff to monitor people’s health and the need for outside support. Service users are generally well protected by the way that their medication is dealt with. Service users are supported by competent and qualified staff. Staff undertake training and receive guidance, which helps to ensure that people are well supported and are not at risk. Checks have been carried out on new staff, which helps to ensure that they are suitable to work in the home. Service users are encouraged to raise any concerns that they may have and to make suggestions about the running of the home. The home is well managed and the organisation has systems in place for identifying when improvements are needed. What has improved since the last inspection?
The uncertainty about one service user’s tenancy at 29 West Ashton Road has been resolved and this person has now left the home. A period of stability followed and two new people then moved into 29 West Ashton Road. The new service users have established their own routines and got to know the local area. People living in the home generally get on, although there have been incidents between particular service users during the last year that have needed to be followed up. The Community Team for People with Learning Disabilities (CTPLD) has been involved, although there had been concerns that not all the relevant incidents were being reported at the appropriate time. There has been discussion about this, to ensure that there is a consistent approach about what needs to be reported and shared with other agencies. New procedures have been agreed. As a result, service users can feel more confident that any incidents affecting their welfare and safety will be responded to in the right way. There was a requirement at the last inspection that some additional information is included in the home’s medication procedure. This has now
DS0000028350.V344569.R01.S.doc Version 5.2 Page 7 been added, so that there is more comprehensive guidance about how medication should be dealt with in particular circumstances. Redecoration has continued in the home. Service users choose the colour schemes in their own rooms and there is discussion about what people would like in the communal areas. The hall now has a more modern and coordinated appearance. Some new facilities have also been provided in the bathroom and the kitchen. 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. DS0000028350.V344569.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 DS0000028350.V344569.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): 2 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including the visits to the home. Prospective service users visit the home and have their needs assessed before moving in. EVIDENCE: One service user had left 29 West Ashton Road since the last inspection and two new service users had moved into the home. They spoke about the visits that they had made to see the home and to meet people. Both people had received support from care managers with the arrangements for moving into the home. Community care assessments had been undertaken and copies of these were kept in the service users’ personal files. The placing authorities had also completed care plans prior to the admissions. Further information had been recorded after the service users moved in about their needs and their preferred routines and activities. Service users had been supported with completing a ‘My Life Story’ form and a ‘What my needs are’ assessment record. In their surveys, each service user confirmed that they had been asked if they wanted to move to the home. One person commented that they had visited a few times and had tea to meet the people before moving in.
DS0000028350.V344569.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including the visits to the home. Service users’ needs and personal goals are reflected in their individual plans. Service users can make decisions about what they want to do. They are supported to take risks within their capabilities. EVIDENCE: Each service user had an individual support plan that had been reviewed and updated within the last two months. Service users had signed the original plans, which covered a wide range of needs. There was a form for staff to confirm that they had read the relevant records. Some people’s support plans had been produced in different formats, for example large print and in an audio version, in order to meet their individual needs. DS0000028350.V344569.R01.S.doc Version 5.2 Page 11 Particular preferences and areas of need were also reflected in other records, such as a ‘Daily Routine’ form and an ‘Intimate and Personal Care Statement’. Service users were meeting with a member of staff each month as part of the home’s keyworker system. The outcomes of these meetings were being recorded. It was seen on one of the new service user’s files that they had signed an agreement to meet with their keyworker each month, to discuss goals and to monitor their progress. Areas of risk had been identified in the service users’ individual support plans and these linked to risk assessments that had been separately recorded. Assessments had been completed for a range of activities undertaken by service users, for example riding a bike and travelling independently. The risk assessment forms showed the benefits of a service user being able to take part in a particular activity and also the risks arising from them not doing this. This showed that independence and decision making by service users was being promoted, whilst action was being taken that helped people to be safe. Decisions about the service users’ personal goals and needs were being made at review meetings to which people from outside the home were invited. The daily records and the keyworker meeting reports showed that service users were regularly making decisions about their day to day affairs. House forum meetings were being held about once a month, with minutes kept in large print format. At the last meeting in June 2006, service users had talked about having a barbeque and producing a newsletter. People had also been asked if they had any concerns that they would like to raise. Service users said that there were no ‘house rules’ that they did not agree with. Smoking was only allowed outside the home. One service user mentioned that the kitchen door was kept locked after 10 pm. This was later discussed with Mrs Carwithen, who said that this was being tried, as food was going missing from the fridge and turning up elsewhere. There was a concern about certain foodstuffs being eaten, which had been out of the fridge for some time. Mrs Carwithen recognised that this was not an ideal situation and was hoping to be able to stop it happening without the need to lock the door. It was agreed that the situation would be kept under review. Subject to the restriction affecting access to the kitchen, service users were able to use all areas of the accommodation and grounds independently. The service users’ diverse needs were discussed with Mrs Carwithen. Mrs Carwithen said that the age range of the service users was the main issue to be aware of. In their survey, a relative reported that they felt that there had been an improvement in the age mix recently, with the arrival of two younger people. They also felt that there was a good gender balance at this time. DS0000028350.V344569.R01.S.doc Version 5.2 Page 12 Another person expressed concerns about the journeys that their relative in the home makes on their own and the risk that this involves. A meeting involving the relevant parties was to be held to discuss this and other matters. DS0000028350.V344569.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including the visits to the home. Service users are part of the local community and have well established links within the area. They receive support with relationships and have different routines and occupation, which reflect their individual interests and abilities. Service users can help to plan and prepare the meals. EVIDENCE: The service users’ personal files contained information about their preferred routines, relationships and interests. This included ‘Family contact’ forms and ‘Special date’ lists, which provided staff with information that would help them to support service users appropriately. Weekly timetables had been written which showed how the service users spent their time. Regular activities included attending college courses and different day services.
DS0000028350.V344569.R01.S.doc Version 5.2 Page 14 People also had unstructured time during the week when they could follow their own routines. One service user said that they went out each day on a shopping trip, which they fitted in around other commitments. Another service user visited their relatives regularly and was getting used to making the journeys independently. All service users, except one person, were able to go out by themselves; the circumstances having been agreed in advance as part of their risk assessments. One service user was a season ticket holder at a local football club and was looking forward to the start of the new season. Some people talked about a local internet café that they enjoyed going to. One service user had recently finished a college course. Staff were helping the person to find part-time work, with support from a job coach. Service users were engaged in various activities when the home was visited. Service users took responsibility for opening the front door on both occasions. People who had been out during the day on 26 June quickly settled into their own routines when they returned home. One person helped to prepare cottage pie for the evening meal and another person laid the tables. There was a rota for different jobs in the home. One service user had pet guinea pigs to look after. Some people liked relaxing in the lounge watching television. The quality of the television picture was not good, which staff thought might be an aerial problem. They said that this would be followed up. Service users were using the garden, which was easily reached from the back of the house. Vegetables were being grown in one part of the garden; the evening meal included home grown potatoes. The meal was ready in time for some people to be able to go out to a club in the early evening. Staff checked the arrangements that had been made for this. A service user confirmed that they had booked a taxi on behalf of the people who wanted to go. Staff then reminded people about the need to ensure that everybody contributed equally to the costs. Paying for the taxi involved people withdrawing money that was being kept safe for them in the home. People were involved in obtaining their personal allowances and then received support from staff with budgeting and its safekeeping in the home. Records were kept of the transactions. Service users had tea together in the dining room. One person came home later during the meal and their food was kept warm for them. Meals were prepared following a planned menu. The service users’ choice of meals was discussed with them and people said that they could decide to have an alternative on the day, for example if they did not like fish. People said that they made their own breakfasts, with support available from staff. DS0000028350.V344569.R01.S.doc Version 5.2 Page 15 In their survey, a relative reported that involving service users in social events, which suited their inclinations, was something that the home did well. The relative also commented positively about the support that service users received with finding and attending suitable college courses; with attending church services and with developing their interests, such as painting and music. The Community Team for People with Learning Disabilities (CTPLD) commented that the staff team were creative in developing links for people with their local community resources. DS0000028350.V344569.R01.S.doc Version 5.2 Page 16 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. The service users’ personal and health needs are being met. They are generally well protected by the way that their medication is dealt with. EVIDENCE: The service users’ individual plans showed that support from staff mainly consisted of prompting and encouragement. Staff supported people with some specific tasks. Risk assessments had been undertaken in areas such as showering and bathing. Guidelines for staff had been produced as a result of the assessments. As part of the contractual arrangements, two service users had staff hours allocated to them for one to one support. Much of this time was to be spent on developing the service users’ independence, for example when visiting family and in their daily routines. The outcome of this additional support was not being recorded. Service users looked well supported with their personal care and appearance. Mrs Carwithen said that staff did not provide support with toenail cutting and that service users went to a podiatrist for which they were not charged.
DS0000028350.V344569.R01.S.doc Version 5.2 Page 17 The service users’ personal files included evidence of health checks and appointments with dentists, G.P.s and other health professionals. The Community Team for People with Learning Disabilities in Trowbridge had provided support for people with their specialist needs. A staff member said that service users were registered with different GPs at three local surgeries and that each proved provided good support. One person had an appointment with an optician shortly after moving into the home, which had been beneficial for them. Arrangements were being made for one service user to be admitted to hospital for an operation. There was a medication file which contained a procedure for the administration of medication to service users. This had been amended since the last inspection to include some additional details. The file included information about the medication that service users were prescribed and its possible side effects. Following assessment, service users could take responsibility for their own medication, or a part of it. One service user was looking after a limited supply of their medication and separate guidelines had been produced about the arrangements for this. The other service users were receiving support from staff with the administration and safekeeping of their medication. Service users had signed ‘Consent to treatment’ forms, which were kept on file. Records were kept which showed when staff had administered the medication. No PRN (as required) medication was being prescribed. Records were up to date. The medication administration records for one service user included a hand written entry that had not been initialled by staff, although information about changes in prescriptions and medication reviews had been recorded elsewhere. The need to for staff to initial the record was confirmed with Mrs Carwithen, who said that this would be followed up with staff. Staff members received ‘in-house’ training in the medication procedures and also had the opportunity to attend an external course. DS0000028350.V344569.R01.S.doc Version 5.2 Page 18 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. Service users are listened to. Action is being taken, so that service users can be confident about the arrangements being made for their protection. EVIDENCE: The Mencap complaints procedure was on display in the home. Service users had also been given information about making a complaint to keep in their rooms. In their survey, one service user stated that they had a talking book which told them what they needed to do if they had a complaint and who they could speak to. Two other service users mentioned the cards that they had been given and could send off if they wanted to talk to somebody outside the home. Mrs Carwithen confirmed that no complaints had been received during the last year from outside the home. Relationships between people within the home had not always been positive and since the last inspection one service user had made a complaint about the actions of another person. This had been followed up through the local procedures for safeguarding vulnerable adults. The Community Team for People with Learning Disabilities (CTPLD) was involved. They expressed concerns about a lack of consistency and sharing of information by the home about certain incidents, which had come to light during the investigation. DS0000028350.V344569.R01.S.doc Version 5.2 Page 19 The CTPLD Team Manager had addressed these concerns with Mrs Carwithen at the time. The CTPLD Team Manager has reported that they were now confident that their concerns had been taken on board and measures taken by the home to ensure that it did not happen again. These included a clear procedure, which had since been put in place for the reporting of incidents. During the visit on 29 June, Mrs Carwithen confirmed the procedures that were in place for the reporting of incidents to the appropriate parties. Another, unrelated, incident arose at the time of the visits. Staff promptly followed this up and involved other agencies. Information was also received by the Commission in the form of a regulation 37 notification. The risk assessments completed for service users included one in respect of their ‘General Vulnerability’. DS0000028350.V344569.R01.S.doc Version 5.2 Page 20 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 home environment and its location are meeting the service users’ needs. EVIDENCE: 29 West Ashton Road is a semi-detached property with a large garden. The location of the home meant that service users could go out independently to shops and other facilities that they liked to use. There were bus routes nearby which service users could use, for example when visiting their relatives. The home was owned by a housing association, which took on responsibility for its upkeep and the refurbishment of some areas. The home looked well maintained and decorated. Refurbishment work had been undertaken during the last year, as had been identified in the home’s annual development plan. Redecoration was carried out as part of a five-yearly cycle of works. Bedrooms have been redecorated since the last inspection and the hall had a makeover, which gave it a more modern appearance. Service users had chosen the
DS0000028350.V344569.R01.S.doc Version 5.2 Page 21 colour schemes in their own rooms and had discussed their ideas for the communal areas. Facilities in the bathroom and the kitchen had been improved and new dining room furniture bought. Relocation of the bathroom has previously been recommended although this is not thought to be a feasible proposition. During the inspection, service users were using their own rooms as well as mixing with others in the lounge. The lounge was comfortably furnished and had a television and video. It was seen that the television picture was quite grainy for a modern set. Staff thought that it was likely to be an aerial problem that could be put right. Service users thought that they got a better picture on the televisions in their own rooms. A separate dining room was available for quieter and more individual activities. The garden was large and easily accessible from the home. It provided a good space for recreation and entertaining. Plans were being made for the garden to be further developed. Laundry was being carried out in a utility area that was separate to the kitchen. The accommodation looked clean and tidy. In their survey, a relative reported that they had noticed an improvement in the facilities, both in the things replaced within the home and also in the maintenance of existing fittings. DS0000028350.V344569.R01.S.doc Version 5.2 Page 22 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. Service users are supported by competent and qualified staff, who are undertaking appropriate training. They are protected by the home’s recruitment practices. EVIDENCE: Information had been received prior to the visits about staff training and qualifications. All the support workers, except one person, had achieved a National Vocational Qualification (NVQ) in Care at Level 2 or above. This represented 85 of the staff team. Mencap had produced an induction programme for new staff, which was consistent with the national standard for staff working in a learning disability service. A staff member who was met with confirmed that they had undertaken a planned programme of induction, which they thought had covered the necessary topics. Two new staff members had been appointed since the last inspection. Their recruitment and employment records were looked at in the home. These files
DS0000028350.V344569.R01.S.doc Version 5.2 Page 23 were well organised and contained the required references and documentation in respect of Criminal Record Bureau (CRB), Protection of Vulnerable Adults (POVA) list, medical fitness and other checks. Arrangements were being made for staff to receive training in accordance with Mencap’s policies and procedures for staff development. Staff were required to attend a range of courses that covered mandatory and other care related topics. Courses in medication, first aid and manual handling had been arranged during the last year. Training in care related topics had included ‘Person Centred Approach’, ‘Death, Dying and Bereavement’ and ‘Autism’. Two staff members had achieved NVQ at Level 3. All staff held first aid certificates. Training in dementia had been identified as a training need for the staff team. Mrs Carwithen said that this was going to be arranged. The staff who were met with during the visits confirmed the training and qualifications that they had undertaken. They thought that the training provided was relevant and of a good standard. One person said that they were shortly to receive training to be a fire marshal for the home. The manager and staff team were meeting together about once a fortnight. The minutes of the meetings looked very comprehensive and showed that a range of topics were being discussed. The meetings were an opportunity to share information and to talk about the service users’ current needs. DS0000028350.V344569.R01.S.doc Version 5.2 Page 24 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 excellent. This judgement has been made using available evidence including the visits to the home. Service users benefit from a well run home. Their health and safety are protected by the systems in place. The service users’ views are being sought and they benefit from the home’s approach to quality assurance. EVIDENCE: Mrs Carwithen took over the management of 29 West Ashton Road after having worked and had management experience at another Mencap run home. Mrs Carwithen has achieved the Registered Managers Award and NVQ in care at level 4. DS0000028350.V344569.R01.S.doc Version 5.2 Page 25 People who gave feedback about the home as part of this inspection have commented positively about different aspects of the home. This included comments about the manager being held in high esteem and having overseen a number of improvements in the home. A general comment made by the Community Team for People with Learning Disabilities was that the home provided an excellent service to the people who lived there. Staff members said that they felt well supported, through formal supervision meetings and also through the management approach that they experienced in the home. On-going quality assurance was evident in the service users’ meetings and in the way that the day to day views of service users were being followed up. The home was obtaining feedback through the use of stakeholder and service user surveys. Mencap had devised a system of quality assurance that included the production of a ‘Continuous Improvement Plan’. There was a copy of the current plan in the home. This showed what needed to be improved, how this was identified and how the improvement would be made. Dates were recorded for achieving the improvements. Information about health and safety, including the maintenance and servicing of equipment and the checking of the fire precaution systems was received from the home in a pre-inspection questionnaire. Some health and safety records were looked at in the home. The home’s fire risk assessment had last been reviewed in July 2006 and was due to be reviewed again in July 2007. Risk assessments had been completed for other environmental hazards, such as using equipment in the garden and house security. There was an assessment for lone working by staff, which had been reviewed in June 2007. Health and safety related matters were being discussed at the staff meetings and the service users’ house forum meetings. DS0000028350.V344569.R01.S.doc Version 5.2 Page 26 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 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 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 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 3 X X 3 X DS0000028350.V344569.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action 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 YA18 Good Practice Recommendations That a record is kept of the outcome of the one to one support that service users receive through their additional staff hours. This is recommended in order that people’s progress can be better monitored. DS0000028350.V344569.R01.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: 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 DS0000028350.V344569.R01.S.doc Version 5.2 Page 29 - 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!
